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a to revise - phase 3a > GERIATRICS TO DO > Flashcards

GERIATRICS TO DO Flashcards

1
Q

DELIRIUM
What are some other causes of delirium?

A
  • Urinary retention, vascular events (CVA, MI)
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2
Q

DELIRIUM
What is the ICD-10 diagnostic criteria for delirium?

A
  • Impaired consciousness + inattention (poor conc, memory deficit, “clouding of consciousness”)
  • Perceptual OR cognitive disturbance (agitation, hallucinations > Lilliputian)
  • Acute onset + fluctuating course (often worse at night = sundowning)
  • Evidence it may be related to a physical cause
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3
Q

DELIRIUM
What is a suitable screening tool for delirium?

A

4AT (≥4 = likely) –
- Alertness
- AMT4 (age, DOB, hospital name, year)
- Attention (list months backwards)
- Acute change or fluctuating course

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4
Q

DEMENTIA
What is dementia?

A
  • Syndrome of acquired, chronic, global impairment of higher brain function in an alert patient, which interferes with ability to cope with daily living
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5
Q

DEMENTIA
How does subcortical dementia present?
Give some examples

A
  • Psychomotor slowing, impaired memory retrieval, depression/apathy, executive dysfunction, personality change, language preserved
  • PD, Huntington’s, alcohol-related + AIDS
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6
Q

DEMENTIA
What might a MMSE score indicate in dementia?

A

MMSE (/30) –
- 21–26 = mild, 14–20 = mod, 10–14 mod-severe, <10 = severe cognitive impairment

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7
Q

ALZHEIMER’S DISEASE
What is the clinical presentation of Alzheimer’s

A

4As of Alzheimer’s –
- Amnesia (recent memories poor, disorientation about time)
- Apraxia (unable to button clothes, use cutlery)
- Agnosia (unable to recognise body parts, objects, people)
- Aphasia (later feature, mixed receptive/expressive)
Insidious + progressive course of short-term memory loss Sx in early disease

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8
Q

FT DEMENTIA
What is the management of FT dementia?

A
  • No specific treatment
  • SSRIs may help behavioural symptoms
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9
Q

FALLS
How may rhabdomyolysis present?

A
  • Urine may be dark (‘Coca-Cola urine) + urinalysis +ve to Hb but without RBCs
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10
Q

POSTURAL HYPOTENSION
What are some iatrogenic causes of postural hypotension?

A

Diuretics, anti-hypertensives, antidepressants, polypharmacy

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11
Q

POSTURAL HYPOTENSION
What is the pharmacological management of postural hypotension?

A
  • Med review + stop causative agent
  • Fludrocortisone (raises BP by raised Na+ levels + affecting blood volume) but can cause uncomfortable oedema
  • Midodrine (when cause if autonomic dysfunction) but can cause retention, itchy scalp + paraesthesia
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12
Q

PRESSURE ULCERS
What are the different grades for pressure ulcers?

A
  • 0 = skin hyperaemia
  • I = non-blanching erythema with intact skin
  • II = broken skin or blistering (epidermis ± dermis only)
  • III = full-thickness skin loss involving damage/necrosis of subcutaneous tissue
  • IV = extensive loss, destruction/necrosis of muscle, bone, joint or tendon
  • Unstageable = depth unknown, base of ulcer covered by debris
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13
Q

MALNUTRITION
How is malnutrition defined?

A
  • BMI <18.5kg/m^2
  • Unintentional weight loss >10% in last 3–6m
  • BMI <20kg/m^2 AND unintentional weight loss >5% in last 3–6m
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14
Q

MALNUTRITION
What investigations would you do in someone with malnutrition?

A
  • U+Es, LFTs + ECG prior to commencing feedings
  • Serum albumin often marker of nutrition (can be inaccurate)
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15
Q

MALNUTRITION
What are the components of MUST?

A
  • BMI = 18.5-20 (1), <18.5 (2)
  • Hx of weight loss = 5-10% (1) ≥10% (2)
  • Acutely unwell or likely to have no intake >5d (2)
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16
Q

OSTEOPOROSIS
What is the pathophysiology of osteoporosis?

A
  • Imbalance between modelling + resorption
  • Inadequate formation of new bone during remodelling occurs
  • Excessive bone resorption (PTH can trigger this as RANK-ligand binds to RANK activating osteoclasts)
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17
Q

OSTEOPOROSIS
What is the role of PTH?

A
  • Released from chief cells of parathyroid gland in response to low serum Ca2+ detected by Ca2+ sensor cells
  • Increased osteoclast activity, increased intestinal Ca2+ absorption, vitamin D activation + renal tubule reabsorption of Ca2+
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18
Q

OSTEOPOROSIS
What are 2 important factors in osteoporosis development/primary causes?

A
  • Increasing age
  • Post-menopause as oestrogen is protective
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19
Q

OSTEOPOROSIS
What are the secondary causes/risk factors for osteoporosis?

A

SHATTERED
- Steroids
- Hyper/hypothyroid
- Alcohol/smoking
- Thin (low BMI)
- Testosterone low (F)
- Early menopause
- Renal/liver failure
- Relatives (FHx)
- Erosive bone disease (RA)
- Dietary Ca2+ low

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20
Q

OSTEOPOROSIS
What factors are assessed in the FRAX score?

A
  • Personal = age, sex, weight, height
  • PMH = RA, previous #, secondary osteoporosis (renal/liver disease, coeliac, thyroid issues)
  • DH = glucocorticoids, lithium
  • FHx = parental hip #
  • Social = smoking, alcohol (≥3 drinks/day)
  • Other = femoral neck BMD
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21
Q

OSTEOPOROSIS
What is the overall management of fragility fractures?

A
  • Any patient should have calcium + vitamin D supplementation as well as bisphosphonate regardless of biochemistry as usually normal anyway
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22
Q

OSTEOPOROSIS
What is an alternative to HRT?

A
  • Selective oestrogen-receptor modulators (SERMs) like raloxifene
  • Less breast cancer risk as stimulates oestrogen receptors just on bone
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23
Q

OSTEOPOROSIS
How do bisphosphonates, denosumab, HRT + SERMs compare to teriparatide?

A
  • First lot are anti-resorptive meds which inhibits osteoclast activity + bone turnover
  • Teriparatide is anabolic which increases osteoblast activity + bone formation
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24
Q

OSTEOPOROSIS
Give some examples of bisphosphonate regimes

A
  • PO 70mg alendronate once weekly
  • PO 35mg risedronate once weekly
  • IV 5mg zoledronate once yearly
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25
Q

OSTEOPOROSIS
What are some adverse effects of bisphosphonates?

A
  • Reflux + oesophagitis
  • Osteonecrosis of jaw
  • Atypical stress # (proximal femoral shaft)
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26
Q

PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?

A
  • Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD
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27
Q

PHARMACOLOGY
Give an example of NMDA?

A
  • Memantine
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28
Q

URINARY RETENTION
What are some causes of urinary retention?

A
  • BPH (#1 cause in men)
  • Urethral strictures
  • Anticholinergics
  • Alcohol
  • Constipation
  • Infection
  • Cancer
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29
Q

URINARY RETENTION
What other management is there for urinary retention?

A
  • Catheterise acutely with ?intermittent self-catheterisation at home needed
  • Alpha-blocker tamsulosin to relax muscles in bladder neck making easier to urinate (+ effect on prostate for BPH)
30
Q

LEWY-BODY DEMENTIA
What might it be confused with?

A
  • Delirium due to fluctuating consciousness + hallucinations
31
Q

FT DEMENTIA
What are some pathological features of frontotemporal dementia?

A
  • Microscopic = ubiquitin + tau deposits
32
Q

MILD COG IMPAIRMENT
How does it present?

A
  • Reduced fluency + some short-term memory difficulties
33
Q

FALLS
What markers are elevated in rhabdomyolysis?
Is that an issue?

A
  • K+, phosphate, myoglobin + creatinine kinase
  • Myoglobin is nephrotoxic as causes acute tubular necrosis
34
Q

POSTURAL HYPOTENSION
What are some endocrine causes of postural hypotension?

A

DM, hypoadrenalism, hypothyroidism

35
Q

POSTURAL HYPOTENSION
What are some neuro causes of postural hypotension?

A

PD + PD+ syndromes

36
Q

PRESSURE ULCERS
What are some risk factors for pressure ulcers?

A
  • Peripheral vascular disease (poor healing, reduced tissue perfusion)
  • Immobility (#, pain)
  • Dehydration + malnourishment
  • Obesity
  • Incontinence
37
Q

MALNUTRITION
What do the MUST scores mean?

A
  • 1 = medium risk (observe, if inadequate set goals to improve intake)
  • ≥2 = high risk (refer to dietician, set goals to improve intake)
38
Q

MALNUTRITION
What are the disadvantages of enteral feeding?

A
  • Tolerance (nausea, satiety, bowels both constipation + diarrhoea),
  • tube can be uncomfortable to place,
  • reduced QOL
  • appearance issues
39
Q

PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?

A
  • D+V,
  • nausea,
  • abdo pain (work systemically so GI upset)
  • bradycardia
40
Q

PHARMACOLOGY
When should NMDA be avoided?

A

Do not give in renal failure (low GFR) as nephrotoxic

41
Q

PHARMACOLOGY
What are some side effects of NMDA?

A
  • Confusion,
  • hallucinations,
  • agitation,
  • paranoid delusions
42
Q

END OF LIFE CARE
In terms of managing end of life care, what should be given for agitation, anxiety, or dyspnoea?

A

Midazolam

43
Q

BPPV
what are the causes?

A

50-70% = primary (idiopathic)

secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines

44
Q

HEART FAILURE
what are the risk factors for heart failure?

A
  1. > 65 y/o
  2. African descent
  3. Men
  4. Obesity
  5. Previous MI
45
Q

HEART FAILURE
what is the pathophysiology?

A

When the heart fails, compensatory mechanisms attempt to maintain CO
As HF progresses, these mechanism are exhausted and become pathophysiological

46
Q

HEART FAILURE
What are the compensatory mechanisms in heart failure?

A
  1. Sympathetic system
  2. RAAS
  3. Natriuretic peptides
  4. Ventricular dilation
  5. Ventricular hypertrophy
47
Q

HEART FAILURE
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation

A

Improves ventricular function by increasing HR and contractility = CO maintained
BUT it also causes arteriolar constriction which increases afterload and so myocardial work

48
Q

HEART FAILURE
Explain how the RAAS system is compensatory in heart failure and give one disadvantage of RAAS activation

A

Reduced CO leads to reduced renal perfusion, this activates RAAS –> increased fluid retention so increased preload
BUT it also causes arteriolar constriction which increase afterload and so myocardial work

49
Q

HEART FAILURE
Give 3 properties of natriuretic peptides that make them compensatory in heart failure

A
  1. Diuretic
  2. Hypotensive
  3. Vasodilators
50
Q

HEART FAILURE
what are the clinical signs of left heart failure?

A
  1. Pulmonary crackles
  2. S3 and S4 and murmurs
  3. Displaced apex beat
  4. Tachycardia
  5. fatigue
51
Q

HEART FAILURE
what are the clinical features of right HF?

A
  1. Raised JVP
  2. Ascites
  3. peripheral oedema
52
Q

HEART FAILURE
what are the clinical features of heart failure?

A

SOFA PC
- shortness of breath
- orthopnea
- fatigue
- ankle swelling
- pulmonary oedema (due to backflow from decreased CO; produced cough with pink frothy sputum)
- cold peripheries

Raised JVP
End respiratory crackles

53
Q

HEART FAILURE
what is the management for chronic HF?

A

1st line = ACEi, beta blocker
2nd = ARB + nitrate
3rd = cardiac resynchronization or digoxin
4th = diuretics (furosemide)
5th = aldosterone antagonist (spironolactone)

54
Q

CONSTIPATION
what are the primary and secondary causes?

A

Primary
- disordered regulation of colonic and anorectal neuromuscular function
- IBS

Secondary
- metabolic - hypercalcaemia, hypothyroidism
- medicines - opiates, CCBs, antipsychotics
- neurological disorders - parkinsons, spinal cord lesions, DM
- bowel diseases - cancer, stricture, anal fissure

55
Q

CONSTIPATION
what are the red flag symptoms?

A

Rectal bleeding
Haem-positive stool
Weight loss
Obstructive symptoms
Recent onset of symptoms
Rectal prolapse
Change in stool calibre
Age >50 years.

56
Q

CONSTIPATION
what is the management?

A
  • treatment of underlying cause
  • increased dietary fibre
  • increased fluid intake
  • exercise
  • bulk laxatives
  • stool softeners
  • osmotic laxatives - lactulose, macrogol
57
Q

COTE ASSESSMENT
What is frailty?

A
  • State of increased vulnerability resulting from ageing-associated decline in reserve + function across multiple physiological systems resulting in compromised ability to cope with everyday or acute stressors
58
Q

COTE ASSESSMENT
What are the geriatric giants?
What do they represent?

A 
4Is –
- Instability (falls)
- Immobility
- Intellectual impairment (confusion)
- Incontinence
They are not diagnoses but more general things that COTE pts present with, often indicator of underlying problem
59
Q

COTE ASSESSMENT
What are the geriatric 5Ms?

A
  • Mind = dementia, delirium, depression
  • Mobility = impaired gait + balance, falls
  • Medications = polypharmacy, medication burden, adverse effects, de-prescribing/optimal prescribing
  • Multi-complexity = multi-morbidity, biopsychosocial
  • Matters most = individual meaningful health outcomes + preferences
60
Q

POLYPHARMACY
What is pharmacodynamics?
How does this change for the elderly?

A
  • What the DRUG does to the BODY

- In elderly, effects of similar drug conc. may be different to younger so prone to adverse drug reactions

61
Q

POLYPHAMRACY
What is pharmacokinetics?
How does this change for the elderly?

A
  • What the BODY does to the DRUG
  • Changes in absorption, distribution, metabolism + excretion of drugs
  • May mean drugs hang around longer or elderly pts may experience more toxicity from smaller dose
62
Q

POLYPHARMACY
Give some specific pharmacokinetic issues in geriatrics.

A
  • Hepatic first pass metabolism declines
  • Reduced absorption as gastric pH increases due to atrophy
  • Vascular system less responsive due to calcification of vessels
63
Q

POLYPHARMACY
What is the impact of adverse drug reactions?
What specific issue can this impose in geriatrics?

A
  • Increasing fragility means reduced ability to cope with ADRs
  • May go unnoticed as Sx mimic problems associated with elderly (forgetfulness, weakness, tremor)
64
Q

POLYPHARMACY
What are some common adverse drug reactions in geriatrics?

A
  • Falls (postural hypotension with ACEi, beta-blockers)
  • Confusion (sedation with anticholinergics)
  • Bowel problems (opioids, PPIs)
65
Q

MENTAL CAPACITY ACT
What is the purpose of the Mental Capacity Act, 2005?

A
  • Empower + protect people >16y who lack capacity to make their own decisions about their care + treatment since 1/10/07
66
Q

MENTAL CAPACITY ACT
What is the two-step test in MCA?

A
  • Does the person have an impairment of their mind or brain? E.g. dementia, severe LD, brain injury, coma
  • Is this impairment significant enough to deem them unable of making a particular decision?
67
Q

MENTAL CAPACITY ACT
What are the 5 principles underpinning the MCA?

A
  • Assume capacity until proven otherwise
  • Maximise decision-making capacity (all practical support to help them make decision given)
  • Freedom to make seemingly unwise choice (unwise decision ≠ incapacity)
  • All decisions on behalf of patient in best interests
  • Least restrictive option should be chosen
68
Q

BEST INTERESTS
What are some important considerations when making best interest decisions?

A
  • Encourage participation of the patient wherever possible
  • Find out person’s views (past + present wishes, feelings, beliefs + values)
  • Avoid discrimination (don’t make assumptions on any personal features)
  • Regaining capacity (can the decision wait?)
  • Identify all relevant circumstances to identify what they would have taken into account if they were making this decision
69
Q

DOLS
What is the acid test for DoLS?

A

Must meet 3 criteria –

  • Lack of capacity to consent to the arrangements or their care
  • Subject to continuous supervision + control
  • Not free to leave their care setting
70
Q

MEDICO-LEGAL ASPECTS
What is an advanced refusal of treatments?
Is it legally binding?

A
  • A living will
  • Yes if:
    – Adult ≥18y
    – Was competent + fully informed when made decision
    – Decision is clearly applicable to current circumstances
    – No reason to believe changed mind
71
Q

MEDICO-LEGAL ASPECTS
What is an advanced requests for treatment?
Is it legally binding?

A
  • Patient’s wish for treatment
  • Less legal binding but if it’s patient’s known wish to be kept alive then reasonable efforts (nutrition, hydration) should be considered

a to revise - phase 3a (16 decks)

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