Geris Flashcards
With regards to assessments, what does CGA stand for?
Comprehensive geriatric assessment.
What does CGA involve?
It is a multidimensional and interdisciplinary diagnostic process.
Used to determine the medical, psychological and functional capabilities of a frail older person. Used to develop co ordinated and integrated plan for treatment and follow up (long term).
Who is involved in CGA?
Many health workers.
Geriatricians, nurse specialist, occupational therapist, etc.
CGA areas to cover include:
problem list
meds review
nutritional status
mental health
functional capacity
social circumstances
environment
What’s polypharmacy?
Occurs when 6 or more drugs are prescribed at any one time
Negatives of drugs, particularly of polypharmacy
Iatrogenic problems are not uncommon.
Not all drugs are positive for patient. Many can interact and have side effects. Geriatricians are more likely to discontinue these.
Quick tip: when prescribing drugs, write “u” or “units”?
units
What are the aims of discharge planning (transfer of care)?
- To reduce the patients stay in hospital
- To prevent unplanned re hospital admission
- Improve community services coordination
As part of discharge planning the patient may need extra funds to transfer their care to care homes, if this is in their best interests. What form would be used?
Home first form
Presentation of acutely unwell older persons is typically different to than of a younger patient. How so?
Hypothermic
Change in consciousness (hyper vigilant or withdrawn)
What’s normal body temperature range?
37 +- 0.5
Temperature for hypothermia
Core body temperature is less than 35 degrees celsius
Do the elderly typically complain of being cold?
Many do not complain of feeling cold and therefore have not tried to warm up.
Causes of hypothermia in the elderly?
Impaired homeostatic functions (guess this correlates with age)
Poor, cold housing
Impaired thermoregulation (pneumonia, mi, heart failure)
Reduced metabolism (immobility, diabetes mellitus, hypothyroidism)
Autonomic neuropathy (diabetes mellitus, parkinson’s)
Excess heat loss (e.g.psoriasis) (other dermatology diseases!)
Decrease cold awareness (dementia)
Drugs
Increase cold exposure
How would hypothermia look on ecg?
J wave
What score is used to gauge frailty?
Clinical frailty Scale
Score 1-9
1=healthy 9=most frail
How can we prevent admissions from the community of those older people with chronic conditions?
In the community there are specialist teams (e.g. chronic heart failure teams) that aim to prevent admission
Falls fall into which two categories?
Falls in the elderly fall into two categories:
Either syncopal or non-syncopal
What’s Syncope?
Transient loss of consciousness due to global cerebral hypoperfusion
Causes of syncope?
SNAP
Structural syncope (e.g. obstruction to heart outflow e.g. aortic stenosis)
Neurally mediated syncope (e.g. carotid sinus syndrome, vasovagal)
Arrhythmias syncope (e.g. bradycardia [second degree atrio ventricular block], tachycardia [ventricular tachycardia])
Postural syncope (e.g. medications [antihypertensives, diuretics, tricyclic antidepressants], hypovolemia)
Systems that Control BP?
Short term: baroreceptors(1)
intermediate term and long term: raas(2)and ADH(3)
https://geekymedics.com/regulation-of-blood-pressure/
Body’s response from supine to standing, in terms of BP?
Blood volume shift to lower extremities. Causes decreased pressure sensed by baroreceptors, these receptors then activate autonomic reflexes to increase BP. This mechanism stabilises BP in the short term.
“In case of prolonged upright posture, additional mechanisms are activated, that is activation of the renin-angiotensin-aldosterone system (RAAS) and increased secretion of vasopressin.” (to maintain BP)
https://onlinelibrary.wiley.com/doi/10.1111/jch.13521
This is why all antihypertensive medications can cause postural hypotension (as i was confused why acei/arbs did). But some are most likely to than others. I.e alpha adrenoreceptor blockers act directly on reducing on peripheral vascular resistance and therefore combat the baroreceptor response.
From what I’ve researched, the baroreceptor reflex seems to be the most important in terms of supine to standing BP.
Which causes of syncope have prodromal warning?
e.g. classic pre-syncopal symptoms of nausea, sweating, feeling faint
Particularly Neurally mediated syncope
+
To lesser extent Postural (orthostatic) syncope
Which causes of syncope do not have prodromal warning?
e.g. no classic pre-syncopal symptoms of nausea, sweating, feeling faint
Arrhythmic and structural syncope
An elderly falls, which examinations should be focussed on?
CVS (ecg+lying and standing BP)
Neurological exam
MSK exam (assess joints)
Functional assessment of mobility
Should osteoporosis risk be looked into, for fallen elderly patients too?
Yes
WHat does osteoporosis imply, regarding the bones?
Implies reduced bone mass
75 yr old fractures large bones from minimal trauma. Hence, decided to commence on osteoporosis treatment, what could this include?
Bisphosphonates (=Alendronic acid)
+
Calcium and Vit D if evidence of defiency
Can delirium ans dementia co exist?
Yes
WHat is delirium?
Acute confusional state (with sudden onset+fluctuating course).
Develops over 1-2 days, change in consciousness, hyper or hypoalert+ inattention.
Delirium causes
- underlying medical problem
- substance intoxication
- substance withdrawal
- (combination of those above)
Delirious patients can be hypoactive (withdrawn) or ……..
hyperactive (agitated+confused) or mixed
Delirium is common in older patients in hospital. Risk factors?
Fraility
Sensory impairment
Cognitive impairment
Post surgery
Hip fractures
Severe infection
Delirium causes? (causes to investigate and exclude?)
Anything!
Exclude: electrolyte imbalaces, infection, hypoxia, urinary retention, constipation, uncontrolled pain, drugs (opiates)
How long does delirium last?
Can take time to resolve and can last up to 3 months!
Some people never get back to baseline
What is delirium bad?
Associated with:
Increased mortality
Prolonged hospital admission
increased risk of dementia
Institutionalisation
Delirium management?
- supportive care
- treat underlying cause
- orientate patient to place and time
Distinguish between dementia and delirium how?
Ask family/ reports; “Has there been an acute change from the patients cognitive baseline?”
Collateral history
4AT (bedside test)
What is dementia?
Progressive decline in cognitive functioning usually occuring over several months
Name the types of dementia:
Alzheimer’s disease
Vascular dementia
Lewy body dementia
Frontotemporal dementia
Parkinson’s disease with dementia
Mixed dementia (Alzheimer’s+Vascular type)
Alzheimer’s disease: diagnosis, pathophysiology, drug treatment?
Diagnosis:
Based on clinical history but brain imaging may show disproportionate hippocampus atrophy
Pathophysiology
Accumulation of Beta-amyloid peptide results in progressive neuronal damage, loss of ACh neurotransmitter, etc.
Drug treatment
AChE (Acetylcholinesterase/Cholinesterase) inhibitors; e.g. Donepezil
Vascular dementia: Pathophysiology, onset?
Cumulative effect of many small strokes
Sudden onset and stepwise deterioration
Imaging suggestive of vascular disease
SHould you give acetylcholinesterase inhibitors or memantine to patients suffering from Vascular dementia?
NO
Lewy body dementia: Onset, unqiue symptoms
Gradually progressive.
Have detailed visual or auditory hallucinations.
Later on parkinsonism presents but not severely.
Parkinson’s disease with dementia: features?
Includes features of Parkinson’s [Bradykinesia, tremour, hypertonia]
Confusion occurs later on
Frontotemporal dementia: features?
Presents early, have complex behaviour problems, language dysfunction may occur also.
WHats Mixed dementia?
=Alzheimer’s + Vascular type
Alzheimer’s drug treatment? Drug class, example and therapeutic purpose;
Acetylcholinesterase inhibitors
e.g. Rivastigmine, Donepezil
Slows disease progression
Can AChE inhibitors be used to treat Vascular dementia?
AChE = Acetylcholinesterase
No
Only option with Vascular dementia is to reduce risk factors
Is incontinence a natural part of the aging process?
NO
Types of incontinence
(4 types)
Types of incontinence and there pathophysiology
What does a complete continence examination involve?
In a continence examination, why is it necessary to review the external genitalia (particularly in women)?
See if there’s Atrophic Vaginitis in women.
This can cause incontinence
1st line management of incontinence in older patients?
2nd line management of incontinence in older patients?
Cholinergic receptors = Acetylcholine receptors
What are cholinergic receptors neurotransmitter?
Extra stuff
ACh
acetylcholine
Anticholinergics block cholingeric receptors. Name the two types of anticholinergics (i.e. what receptors they act on)
The two types of ACh receptors seen in the ANS?
nAChR
mAChR
Recall the ANS neurons (para and symp each respectively) and tell me as much as you can.
- Pre/post ganglionic neuron lengths
- Receptor types
-neurotransmitters
Are nAChR ligand gated ion channels or GCPRs?
mAChR?
Adrenoreceptors?
nAChR= ligand gated ion channels
mAChR= GPCRs (m1, ect)
Adrenoreceptors = GPCRs (alpha1, beta1, ect)
Are most sympathetic post ganglionic neurones noradrenergic (NA)?
i.e: Noradrenline is the neurotransmitter released
Yes
Regarding sympathetic and parasympathetic, are all their pre-ganglionic neurons cholinergic?
i.e. They release ACh as a neurotransmitter
Yes
Why can Faecal incontinence occur in older patients?
If anal tone and sensation are diminished, where is the pathology that we’d be worried about?
Spinal cord
WHats the most common cause of faecal incontinence in elderly patients?
Faecal impaction with overflow diarrhoea
Faecal incontinence assessment involves?
When should faeces only be in the rectum?
WHen passing them!
Can patient opening bowels still be impacted? Whats a sign?
Yes
Smearing
If patient has urinary retention, do a PR too?
Yes
Full rectum and bladder often go together
Serious complications of faecal impaction?
Management of faecal impaction?
Manual evacuation is often last resort in impacted patients, why?
Risk of perforation
If older patient is prescribed meds that cause constipation, what else should they be prescribed with?
A laxative
Elderly patient has chronic diarrhoea, what methods are you going to do to exclude causes?
- bowel imaging
- stool culture
- remove potentially causative meds
- exclude faecal impaction
If all causes of chronic diarrhoea have been excluded, what next?
Focus on firming the stool
What drug can be given in chronic diarrhoea?
Loperamide
WHats a TIA?
Is an ischaemic (usually embolic) focal neurological event leading to deficit with symptoms lasting <24 hours
Patients having a TIA are at risk of having a stroke. But how great is this risk, what score is used to calculate this risk?
ABCD2
Score greater than or equal to 4 indicates high risk
WHat ABCD2 score is needed for high risk?
-Greater than or equal to 4
-Also if a patient has 2 or more TIAs in the past week (crescendo TIA)
WHat should happen to patients deemed high risk by the ABCD2 score?
Patients must be seen by specialist within 24 hours
Whats the management of suspected TIA?
300mg aspirin started immediately
How to investigate TIA?
-bloods
-carotid doppler
-brain scan (MRI/CT)
General treatment of TIA involves?
-lifestyle modifications
-COntrol CV risk factors
-ANtiplatelet drugs
-carotid artery surgery
Whats a crescendo TIA?
two or more TIAs in a week
WHats a strokes?
How do we know if the strokes is due to infarct or haemorrhage?
Emergency treatment of stroke?
Bamford classification?
TYpes of stroke?
TACS
PACS
LAC
POCS
Assessment of stroke tools?
FAST
ROSIER
NIHSS
NIHSS?
If brain scans show a non haemorrhagic cause for stroke, give what?
Stroke management?
Post TIA/Stroke, can you drive?
PAtients with MCA infarction are at risk of? And management?
Stroke differentials?
Space occupying lesion/ Hemiplegic migraine/ Hypo hyper glycaemia
CHA 2 DS 2 - VASc?
Score used to gauge risks of anticoagulation?
ORBIT
THe DOACs?
R E A D
Prioritys of pallative care?
Comfort and dignitiy
Stages in disease trajectory (end of life)?
Death certificate:
Clinical frailty scale?
