GERIATRICS TO DO Flashcards
DELIRIUM
What are some other causes of delirium?
- Urinary retention, vascular events (CVA, MI)
DELIRIUM
What is the ICD-10 diagnostic criteria for delirium?
- 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
DELIRIUM
What is a suitable screening tool for delirium?
4AT (≥4 = likely) –
- Alertness
- AMT4 (age, DOB, hospital name, year)
- Attention (list months backwards)
- Acute change or fluctuating course
DEMENTIA
What is dementia?
- Syndrome of acquired, chronic, global impairment of higher brain function in an alert patient, which interferes with ability to cope with daily living
DEMENTIA
How does subcortical dementia present?
Give some examples
- Psychomotor slowing, impaired memory retrieval, depression/apathy, executive dysfunction, personality change, language preserved
- PD, Huntington’s, alcohol-related + AIDS
DEMENTIA
What might a MMSE score indicate in dementia?
MMSE (/30) –
- 21–26 = mild, 14–20 = mod, 10–14 mod-severe, <10 = severe cognitive impairment
ALZHEIMER’S DISEASE
What is the clinical presentation of Alzheimer’s
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
FT DEMENTIA
What is the management of FT dementia?
- No specific treatment
- SSRIs may help behavioural symptoms
FALLS
How may rhabdomyolysis present?
- Urine may be dark (‘Coca-Cola urine) + urinalysis +ve to Hb but without RBCs
POSTURAL HYPOTENSION
What are some iatrogenic causes of postural hypotension?
Diuretics, anti-hypertensives, antidepressants, polypharmacy
POSTURAL HYPOTENSION
What is the pharmacological management of postural hypotension?
- 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
PRESSURE ULCERS
What are the different grades for pressure ulcers?
- 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
MALNUTRITION
How is malnutrition defined?
- 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
MALNUTRITION
What investigations would you do in someone with malnutrition?
- U+Es, LFTs + ECG prior to commencing feedings
- Serum albumin often marker of nutrition (can be inaccurate)
MALNUTRITION
What are the components of MUST?
- 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)
OSTEOPOROSIS
What is the pathophysiology of osteoporosis?
- 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)
OSTEOPOROSIS
What is the role of PTH?
- 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+
OSTEOPOROSIS
What are 2 important factors in osteoporosis development/primary causes?
- Increasing age
- Post-menopause as oestrogen is protective
OSTEOPOROSIS
What are the secondary causes/risk factors for osteoporosis?
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
OSTEOPOROSIS
What factors are assessed in the FRAX score?
- 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
OSTEOPOROSIS
What is the overall management of fragility fractures?
- Any patient should have calcium + vitamin D supplementation as well as bisphosphonate regardless of biochemistry as usually normal anyway
OSTEOPOROSIS
What is an alternative to HRT?
- Selective oestrogen-receptor modulators (SERMs) like raloxifene
- Less breast cancer risk as stimulates oestrogen receptors just on bone
OSTEOPOROSIS
How do bisphosphonates, denosumab, HRT + SERMs compare to teriparatide?
- First lot are anti-resorptive meds which inhibits osteoclast activity + bone turnover
- Teriparatide is anabolic which increases osteoblast activity + bone formation
OSTEOPOROSIS
Give some examples of bisphosphonate regimes
- PO 70mg alendronate once weekly
- PO 35mg risedronate once weekly
- IV 5mg zoledronate once yearly
OSTEOPOROSIS
What are some adverse effects of bisphosphonates?
- Reflux + oesophagitis
- Osteonecrosis of jaw
- Atypical stress # (proximal femoral shaft)
PHARMACOLOGY
What is the mechanism of action of N-methyl D receptor antagonists (NMDA)?
- Protects brain cells from excess glutamate (excitatory neurotransmitter) released from cells affected by Alzheimer’s to prevent further damage, good for agitation + BPSD
PHARMACOLOGY
Give an example of NMDA?
- Memantine
URINARY RETENTION
What are some causes of urinary retention?
- BPH (#1 cause in men)
- Urethral strictures
- Anticholinergics
- Alcohol
- Constipation
- Infection
- Cancer
URINARY RETENTION
What other management is there for urinary retention?
- 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)
LEWY-BODY DEMENTIA
What might it be confused with?
- Delirium due to fluctuating consciousness + hallucinations
FT DEMENTIA
What are some pathological features of frontotemporal dementia?
- Microscopic = ubiquitin + tau deposits
MILD COG IMPAIRMENT
How does it present?
- Reduced fluency + some short-term memory difficulties
FALLS
What markers are elevated in rhabdomyolysis?
Is that an issue?
- K+, phosphate, myoglobin + creatinine kinase
- Myoglobin is nephrotoxic as causes acute tubular necrosis
POSTURAL HYPOTENSION
What are some endocrine causes of postural hypotension?
DM, hypoadrenalism, hypothyroidism
POSTURAL HYPOTENSION
What are some neuro causes of postural hypotension?
PD + PD+ syndromes
PRESSURE ULCERS
What are some risk factors for pressure ulcers?
- Peripheral vascular disease (poor healing, reduced tissue perfusion)
- Immobility (#, pain)
- Dehydration + malnourishment
- Obesity
- Incontinence
MALNUTRITION
What do the MUST scores mean?
- 1 = medium risk (observe, if inadequate set goals to improve intake)
- ≥2 = high risk (refer to dietician, set goals to improve intake)
MALNUTRITION
What are the disadvantages of enteral feeding?
- Tolerance (nausea, satiety, bowels both constipation + diarrhoea),
- tube can be uncomfortable to place,
- reduced QOL
- appearance issues
PHARMACOLOGY
What are the side effects of acetylcholinesterase inhibitors?
- D+V,
- nausea,
- abdo pain (work systemically so GI upset)
- bradycardia
PHARMACOLOGY
When should NMDA be avoided?
Do not give in renal failure (low GFR) as nephrotoxic
PHARMACOLOGY
What are some side effects of NMDA?
- Confusion,
- hallucinations,
- agitation,
- paranoid delusions
END OF LIFE CARE
In terms of managing end of life care, what should be given for agitation, anxiety, or dyspnoea?
Midazolam
BPPV
what are the causes?
50-70% = primary (idiopathic)
secondary
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines
HEART FAILURE
what are the risk factors for heart failure?
- > 65 y/o
- African descent
- Men
- Obesity
- Previous MI
HEART FAILURE
what is the pathophysiology?
When the heart fails, compensatory mechanisms attempt to maintain CO
As HF progresses, these mechanism are exhausted and become pathophysiological
HEART FAILURE
What are the compensatory mechanisms in heart failure?
- Sympathetic system
- RAAS
- Natriuretic peptides
- Ventricular dilation
- Ventricular hypertrophy
HEART FAILURE
Explain how the sympathetic system is compensatory in heart failure and give one disadvantage of sympathetic activation
Improves ventricular function by increasing HR and contractility = CO maintained
BUT it also causes arteriolar constriction which increases afterload and so myocardial work
HEART FAILURE
Explain how the RAAS system is compensatory in heart failure and give one disadvantage of RAAS activation
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
HEART FAILURE
Give 3 properties of natriuretic peptides that make them compensatory in heart failure
- Diuretic
- Hypotensive
- Vasodilators
HEART FAILURE
what are the clinical signs of left heart failure?
- Pulmonary crackles
- S3 and S4 and murmurs
- Displaced apex beat
- Tachycardia
- fatigue
HEART FAILURE
what are the clinical features of right HF?
- Raised JVP
- Ascites
- peripheral oedema
HEART FAILURE
what are the clinical features of heart failure?
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
HEART FAILURE
what is the management for chronic HF?
1st line = ACEi, beta blocker
2nd = ARB + nitrate
3rd = cardiac resynchronization or digoxin
4th = diuretics (furosemide)
5th = aldosterone antagonist (spironolactone)
CONSTIPATION
what are the primary and secondary causes?
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
CONSTIPATION
what are the red flag symptoms?
Rectal bleeding
Haem-positive stool
Weight loss
Obstructive symptoms
Recent onset of symptoms
Rectal prolapse
Change in stool calibre
Age >50 years.
CONSTIPATION
what is the management?
- treatment of underlying cause
- increased dietary fibre
- increased fluid intake
- exercise
- bulk laxatives
- stool softeners
- osmotic laxatives - lactulose, macrogol
COTE ASSESSMENT
What is frailty?
- 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
COTE ASSESSMENT
What are the geriatric giants?
What do they represent?
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
COTE ASSESSMENT
What are the geriatric 5Ms?
- 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
POLYPHARMACY
What is pharmacodynamics?
How does this change for the elderly?
- 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
POLYPHAMRACY
What is pharmacokinetics?
How does this change for the elderly?
- 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
POLYPHARMACY
Give some specific pharmacokinetic issues in geriatrics.
- Hepatic first pass metabolism declines
- Reduced absorption as gastric pH increases due to atrophy
- Vascular system less responsive due to calcification of vessels
POLYPHARMACY
What is the impact of adverse drug reactions?
What specific issue can this impose in geriatrics?
- Increasing fragility means reduced ability to cope with ADRs
- May go unnoticed as Sx mimic problems associated with elderly (forgetfulness, weakness, tremor)
POLYPHARMACY
What are some common adverse drug reactions in geriatrics?
- Falls (postural hypotension with ACEi, beta-blockers)
- Confusion (sedation with anticholinergics)
- Bowel problems (opioids, PPIs)
MENTAL CAPACITY ACT
What is the purpose of the Mental Capacity Act, 2005?
- Empower + protect people >16y who lack capacity to make their own decisions about their care + treatment since 1/10/07
MENTAL CAPACITY ACT
What is the two-step test in MCA?
- 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?
MENTAL CAPACITY ACT
What are the 5 principles underpinning the MCA?
- 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
BEST INTERESTS
What are some important considerations when making best interest decisions?
- 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
DOLS
What is the acid test for DoLS?
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
MEDICO-LEGAL ASPECTS
What is an advanced refusal of treatments?
Is it legally binding?
- 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
MEDICO-LEGAL ASPECTS
What is an advanced requests for treatment?
Is it legally binding?
- 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
