Geriatrics PTS Flashcards
Define Frailty
- State of increased vulnerability resulting from ageing associated decline in functional reserve
- Across multiple Physiological systems
- Resulting in compromised ability to cope with everyday or acute stressors
What are the 4 components of the comprehensive geriatric assessment?
- Medical assessment
- Functional assessment
- Psychological assessment
- Social and environmental assessment
What is the medical assessment made up of?
- Doctor, nurse, pharmacist, dietician, SALT
- Problem list, comorbidities, medication review, nutritional statues
What mades up the functional assessment?
- OT, PT, SALT
- Assesses ADLs, activity, exercise status, gait, balance
What is the psycological assessment comprised of?
- Doctor, nurse, OT, psychologist
- Cognitive status testing, mood/depression testing (PHQ-9 questionnaire)
What is the social and environmental assessment comprised of?
- OT and social worker if needed
- Informal support needs and assets, care resource eligibility, home safety
What are the features of delirium?
- Acute onset
- Fluctuating course
- Inattention
- Altered level of consciousness
- Usually reversible
- Associated with underlying medical cause
What are the features of dementia?
- Chronic illness
- Progressive course
- No clouding of consciousness
- No underlying/reversible cause
What assessment tool is used for delirium?
4-AT
What causes delirium?
- Infection
- Drug use - withdrawal or new medications interaction
- Reduced sensory input - blind, deaf, changing environment
- Intracranial problems - stroke, seizures, haemorrhage
- Electrolyte imbalances
- Constipation
- Urinary retention
- Heart problems - MI, arrhythmia
How is delirium managed?
- Treat underlying cause
- Manage the environment
6 ways to alter environment to help delirium
- Clocks and calendars to maximise orientation
- Ensure hearing aids/glasses are worn
- Photos of family members
- Consistency of staff members
- Quiet bay/side room if possible
- Sleep hygiene
What are the complications of a long lie following a fall?
- Pressure ulcers
- Dehydration
- Rhabdomyolysis
- Hypothermia
How do you investigate pressure ulcers?
- CRP, ESR
- WCC
- Swabs
- Blood cultures
- X-ray for bone involvement
How are pressure ulcers managed?
- Antibiotics
- Wound dressing
- Pain relief
- Debridement if grade 3/4
What is osteoporosis?
- Decreased bone mineral density due to imbalance between remodelling and resorption
- Increases risk for fractures - particularly spine, hip and neck of femur
7 risk factors for osteoporosis
- Smoking
- Early menopause
- Steroid use
- Underweight
- Inactivity
- Alcohol
- Elderly
How is osteoporosis managed?
- Bisphosphonates - Zoledronate, Alendronate
- IV once a year or oral once a week (on an empty stomach sit upright for half an hour after)
What is the tool used to assess multi-nutritional status?
MUST screening tool (malnutrition universal screening tool)
What is refeeding syndrome?
- Metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished
What are the biochemical features of refeeding syndrome?
- Hypophosphataemia
- Hypokalaemia
- Thiamine deficiency
- Abnormal glucose metabolism
What are some complications of re-feeding syndrome?
- Cardiac arrhythmias
- Coma
- Convulsions
- Cardiac failure
How is re-feeding syndrome treated?
- Monitor blood biochemistry (phosphate, glucose, sodium, potassium)
- Commence re-feeding with guidelines
Risk factors for pressure ulcers
- Peripheral vascular disease
- Immobility/long lie
- Dehydration
- Obesity
- Malnourishment
- Old age
Environmental causes of falls in elderly people
- Loose rugs
- Pets
- Furniture
- Unstable footwear
Power/balance causes of falls in elderly people
- Inactivity leading to muscle weakness
- Dizziness/loss of balance/ loss of proprioception (vertigo)
- Pain, MS, osteoarthritis
- Previous fall leading to decreased confidence
Cardiovascular causes of falls in elderly people
- Vasovagal syncope
- Situational syncope (micturition)
- Postural hypotension
- Myocardial infarction
- Arrhythmia
- Dehydration/shock
Neurological causes of falls in elderly people
- Stroke
- PD
- Gait disturbance
- Visual impairment
- Peripheral neuropathy
- Myopathy
What are some medications that increase risk of falls in elderly people?
- Benzodiazepines (sedative)
- Diuretics
- Anti-hypertensives
- Antidepressants
- Antipsychotics
- Polypharmacy
Miscellaneous causes of falls in elderly people
- Infection/sepsis
- Delirium
- Hypoglycaemia
- Incontinence
- Alcohol (intoxication, neuropathy, Korsakoff’s/Wernicke’s)
5 features of a Parkinsonian tremor
- Pill rolling
- Worse at rest
- Reduced on distraction
- Reduced on movement
- Asymmetrical
What is the underlying pathophysiology of Parkinson’s?
Loss of dopaminergic neurones in the substantia nigra
Whagt class of drug is normally combined with L-dopa therapy to prevent peripheral side-effects?
Carbidopa - a dopa-decarboxylase inhibitor
5 complications of L-dopa therapy
- Development of choreiform movements (L-dopa induced dyskinesia)
- Become tolerant to the medication
- Confusion
- Hallucinations
- Postural hypotension
6 cardiac conditions gthat may cause an embolic CVA
- Atrial fibrillation
- Infective endocarditis
- Atrial-septal defect/ patent foramen ovale
- Mitral regurgitation
- Aortic or mitral valve disease
- Valve replacement
6 Stroke investigations
- ECG
- CT head
- Carotid artery Doppler - carotid artery stenosis can cause ischaemic stroke
- Lipid profile - could have hypercholesterolaemia whihc is a RF for stroke
- Clotting screen - show increased risk of thrombosis or haemorrhage
- Echocardiogram - exclude cardiac sources of emboli
What ABCD2 score is considered “high risk” for a stroke and what should be done?
≥ 4 = high risk
Aspirin – 300mg daily – started immediately
Specialist referral within 24 hours of onset of symptoms
Secondary prevention measures (statins, antihypertensives)
Crescendo TIAs (two or more episodes in a week) should be treated as high risk, regardless of ABCD2 score
What should be done for someone with an ABCD2 score of ≤ 3?
Specialist referral within 1 week of symptom onset, including decision or brain imaging
If vascular territory or pathology is uncertain – refer for brain imaging
What are the components of the GCS?
- Best eye opening response
- Best verbal response
- Best motor response (how well they localise pain)
Causes of delirium
- Infection
- Polypharmacy
- Urinary retention
- Constipation
- Dehydration
- Electrolyte imbalance
- Medication withdrawal
- Stroke
- MI
- B12 deficiency
Non-invasive investigations for delirium
- Full blood count
- ECG to exclude MI
- U&Es
- Urine dipstick to exclude UTI
- Chest X ray to exclude pneumonia
Causes of hyponatraemia
Dilutional effect
- Heart failure
- SIADH
- hypervolaemia
- NSAIDS
- Oliguria renal failure
Sodium loss
- Addison’s
- D&V
- Osmotic diurese (DM, diuretic excess)
- Severe burns
- Acute renal failure
Symptoms of hypocalcaemia
- Muscle cramps/spasms
- Tetany
- Seizures
- Parathesia
- Carpopedal spasm
- Laryngospasm/ brochospasm
Symptoms of hypercalcaemia
BONES, STONES, MOANS, GROANS
- Bone pain, fractures
- Renal stones
- Drowsiness
- Muscle weakness
- Depression
- N&V
- Constipation, abdo pain
What MMSE score supports a diagnosis of dementia?
<25
List cognitive assessment tools
- MMSE
- CP-COG
- Addenbrooke’s
- 6-CIT
- AMT
- MOCA
Types of dementia and their key features
Alzheimer’s – Agnosia, Apraxia, Amnesia, Aphasia
Vascular dementia – stepwise progression of symptoms following ischaemic brain injury
Lewy body dementia – sleep behaviour disorder, falls, impaired consciousness, visual hallucinations, Parkinsonism
Frontotemporal dementia– memory fairly preserved, extreme personality changes and disinhibition
Blood tests to exclude treatable causes of dementia?
- B12, thiamine and folate levels
- Thyroid function
- FBC looking for anaemia
- Syphilis serology
- LFTs
What is Donepezil and what types of dementia can it be used to treated?
Acetylcholinesterase inhibitor (others are rivastigmine and galatamine)
Can only be used to treat Alzheimer’s
Alternative medication – NMDA-receptor antagonist – blocks glutamate (memantine)
What are the 2 subtypes of delirium?
Hyperactive - agitated, inappropriate behaviour, hallucinations
Hypoactive - lethargy, reduced concentration
What are some risk factors for delirium?
Old age
Cognitive impairment
Frailty/multiple comorbidities
Significant injuries (e.g. hip #)
Functional impairment
History of alcohol excess
Sensory impairment (deaf, blind)
Poor nutrition
Lack of stimulation
Terminal phase of illness
How does delirium present?
Acute behavioural change
Disorganised thinking/altered perception
Altered level of consciousness
Falling
Loss of appetite
What bedside tests would you do for someone with delirium?
O2 sats
BP
Temperature
ABG/VBG
What investigations would you do for someone with delirium?
FBC, LFT, U&E
CRP/ESR
Sputum culture
Folate, B12
HbA1C
TFT
CXR, ECG, urinalysis
How do bisphosphates work?
Inhibition of osteoclasts
List 3 adverse effects of bisphosphonates?
Oesophagitis
Osteonecrosis of the jaw
Increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
How are DEXA scan scores interpreted?
-1 to +1 = healthy
- 1 to -2.5 = osteopenia
≤ -2.5 = osteoporosis
≤ 2.5 and a current fragility fracture = severe osteoporosis
What are the components of the FRAX scoring system?
Parent hip fracture
Height and weight (BMI)
Smoking
Alcohol >3 units a day
Steroids
Previous hip fracture
Femoral neck bone mineral density
Female gender
Age
RA
Secondary osteoporosis
How is malnutrition diagnosed?
BMI < 18.5 kg/m2
Unintentional weight loss >10% in the last 3-6 months
BMI < 20kg/m2 plus unintentional weight loss >5% within the last 3-6months
What are some causes of malnutrition?
Inadequate nutritional intake (starvation)
Increased nutrient requirements (cancer, sepsis, injury)
Inability to utilise ingested nutrients (malabsorption)
Increased loss (vomiting, diarrhoea)
Combination of all of them
What tests are important to be done before commencing feeds in malnutrition?
- U&Es
- LFTs
- ECG
What are some clinical features of re-feeding syndrome?
CVS – arrythymias
GI – abdo pain, constipation, vomiting, anorexia
MSK – weakness, myalgia, rhabdomyelosis, osteomalacia
Resp - SOB, ventilator dependence, respiratory muscle weakness
Neuro – weakness, paraesthesia, ataxia
Metabolic – infections, thrombocytopenia, haemolysis, anaemia
Other – liver failure, Wernicke’s encephalopathy
When looking at best interests, what needs to be considered?
Whether the person is likely to regain capacity and can the decision wait
How to encourage and optimise the participation of the person in the decision
The past and present wishes, feelings, beliefs and values of the person and any other relevant factors
Views of other relevant people (family members etc.)
What is the role of an advanced directive?
Allows people who understand the implications of their choices to state their treatment wishes in advance
They can authorise specific procedures
They can refuse treatment in a predefined future situation
What makes an advanced refusal of treatment legally binding?
The person is an adult
The person was competent and fully informed when making the decision
The decision is clearly applicable to current circumstances
There is no reason to believe that they have since changed their mind
What factors would mean the advanced directive had less of a legal binding?
If there is and advanced REQUEST for treatment
This does not have the same legal binding as a refusal of treatment
But if it’s the patient’s known wish to be kept alive then reasonable efforts (nutrition, hydration) should be made
What is deprivation of liberty?
Occurs when a person does not consent to care or treatment
i.e. they cannot consent to the treatment/care but they are having it anyway
For example a person with dementia who is not free to leave a care home and lacks capacity to consent to this
What is a lasting power of attorney?
A document which a person can use to nominate someone else to make certain decisions on their behalf when they are unable to do so themself
It can be financial/about estate, or medical/health decisions
To be valid – it needs to be registered with the Office of the Public Gaurdian
What is the role of an independent mental capacity advocate (IMCA)?
Commisioned from independent organisations by the NHS and local authorities to ensure the MCA is being followed
Role = support and represent the people who lack capacity and do not have anyone else to represent them in decisions (i.e. about long-term accommodation or serious medical treatment)
What is the definition of postural hypotension?
A drop of >20/10 mmHg within 3 minutes of standing
Occurs in 30% of patients over 70
What are some causes of postural hypotension?
Medications – diuretics, antihypertensives, antidepressants, polypharmacy
Cardiac – aortic stenosis, arrythmias, MI, cardiomyopathy, CHF, anaemia
Endocrine – diabetes insipidus, hypoadrenalism, hypothyroid, hypo anything..
Neuro – PD and PD+ syndromes
Blood loss, dehydration, shock
How does postural hypotension present?
Asymptomatic
Falls/syncope
Dizziness
Light-headedness
Blurred vision
Weakness
Fatigue
Palpitations
Headache
How is postural hypotension investigated?
Lying and standing blood pressure
Investigate for medical causes – medication review, blood tests
How is postural hypotension managed?
Drink lots of water
Avoid large meals and alcohol
Exercises
Stand slowly
Sleep with head raised
Pharmacological – fludrocortisone, midodrine (autonomic dysfunction only)
How are pressure ulcers classified?
Grade 1 – non-blanching erythema with intact skin
Grade 2 – partial thickness skin loss involving epidermis, dermis or both (abrasion/blister)
Grade 3 – full-thickness skin loss involving damage/necrosis of sub-cut tissue
Grade 4 – extensive loss, destruction/necrosis of muscle, bone or support structures
Unstageable – depth unknown, base of ulcer covered by debris
What are the 2 major metabolic components of calcium homeostasis?
- Vitamin D
- Parathyroid hormone
What is the role of vitamin D?
Increase Ca2+ absorption in the gut
Increased Ca2+ release from the bone
Where is parathyroid hormone released from and what triggers it’s release?
Secreted from the chief cells of the parathyroid gland
In response to low serum Ca2+ levels (detected by calcium sensor cells in the parathyroid glands)
What is the role/actions of parathyroid hormone?
Acts to increase Ca2+ levels
Causes increased osteoclast activity
Increases intestinal Ca2+ absorption
Increases vitamin D activation
Increases renal tubule re-absorption of Ca2+
How is osteoporosis defined?
Reduction in bone mineral density
And micro-architectual deterioration of bone tissue
With a conseqent increase in bone fragility and susceptibility to fracture
BMD > 2.5 SDs below the mean is diagnostic
T score < -2.5
Where are 4 common sites for osteoporosis related fractures?
Thoracic vertebrae – fractures here may lead to kyphosis and loss of height
Lumbar vertebrae
Proximal femur
Distal radius (Colles’ fracture)
How would you investigate someone with suspected osteoporosis?
DEXA scan – T value < -2.5
Radiology – XR demonstrating fractures
Serum biochemistry – calcium, phosphate, alkaline phosphatase (normal)
Check for secondary causes – thyrotoxicosis, myeloma, hyperparathyroidism, malabsorption
What T score would be seen in someone with osteopenia?
-1 to -2.5
If > - 1 then normal
