Gerries Flashcards
What are the key concepts to consider in CoE?
- Polypharmacy
- Comorbidities
- Extra mental, functional and social issues
- Increased vulnerability
- Complex ethical problems
What is frailty?
diminished strength, endurance, and reduced physiological function
Leading to increased vulnerability to comorbidity and death
What is Parkinson’s disease?
Neuro disease characterised by reduced dopaminergic activity in the substantia nigra
± build up of Lewy body plaques (Lewy body dementia)
What are the 3 main features of Parkinson’s?
Bradykinesia
Tremor
Rigidity
What is a Parkinson’s tremor like?
Slow (pill-rolling)
Improves on distraction and movement
Resting tremor
Asymmetrical
What is the presentation of Parkinson’s?
Tremor
Rigidity
Bradykinesia
- shuffling gait
- masked expression
- lost arm swing
- stooped
- frequent falls
- depression, hallucinations, dementia
- slow movements and speech
What are the complications of L-dopa therapy?
Hallucinations
Postural hypotension
What tools can you use to assess mental health/ cognition?
Mini-Mental State Examination (MMSE) Montreal Cognition Assessment (MoCA) Abbreviated Mental Assessment (AMT) GPCog (GP assessment of cognition) Geriatric Depression Scale: for depression lol
What is assessed in the MMSE:
Orientation Registration Recall Language Visuo/spacial function/ copying Attention and calculation
In the MMSE what score is indicative of cognitive impairment?
/30 in total.
Score <25 indicates dementia
<10 is severe
What are the 4 stages of assessing mental capacity?
- Can they UNDERSTAND information
- Can they RETAIN the information
- Can they use the information to WEIGH up pros/ cons
- Can they COMMUNICATE their decision
What are the domains of a Comprehensive Geriatric Assessment?
Physical health Mental health Functional ability (ADLs) Social circumstances Environment
What is an LPA?
Lasting Power of Attorney;
Advanced care plan to allow another person (usually a relative or friend) to make decisions on your behalf, in the case that you no longer have capacity, in regards to your;
- Health and welfare
- Finances
What needs to be considered when making a decision in the best interest of the patient?
- Patient prior wishes (Advanced statement)
- Patient current wishes
- Balance risk and benefit
What is an advanced statement?
NOT LEGALLY BINDING
Patient statement; verbal or in writing expressing their wishes in regards to future care
Not legally binding but worth considering when making best interest decisions
What are risk factors or aetiology for falling?
Intrinsic;
- Female
- CV disease; blood pressure, aortic stenosis, heart failure, hydration
- Neuro disease; stroke, foot drop, peripheral neuropathies, dementia
- Metabolic imbalances; hypoglycaemia, salts
- Infection
- Cognitive decline
- Vision problems
- Sarcopenia
Extrinsic;
- Polypharmacy
- Drugs: antihypertensives, opiates, diuretics
- Intoxication
- Walking aids
- Functional issues; trip hazards, poor footwear
What should you consider in a falls history?
Use pt. and eye witnesses
- Previous falls
- What happened (mechanical? feeling before fall? LOC?)
- What happened after (immediate care, assess injuries)
- PMH and DH (causes, ?polypharmacy)
- Social history: environment, fall risk, available and required support
What investigations would you want to do after a fall?
- ECG
- Lying and standing blood pressure
Other;
FBC, U+E, LFTs, TFTs, Ca, VitD
DEXA scan
What is the management post fall?
Manage causes/ risk factors;
- e.g. polypharmacy or CV causes etc.
Physiotherapy; improve strength
Occupational therapy; ADL and environmental risk assessment
What is delirium?
Acute and fluctuating disturbance in consciousness, cognition and attention
What are the symptoms/presentation of delirium?
ACUTE ONSET WITH FLUCTUATIONS IN SEVERITY
Often cause present in history
Altered consciousness Psychiatric symptoms; - hallucinations - aggression - confusion - disorientation - speech disorders - mood disorders No insight
What are the causes of delirium?
Pain Infection (e.g. UTI) Nutrition Constipation Hydration Medications Environment/ electrolyte disturbance
What is the assessment tool for delirium?
Confusion Assessment Method (CAM)
or
4AT
MMSE and other similar tools would show inattention
What are the diagnostic features for delirium?
Acute change in cognition ± fluctuations
Inattention
Disorganised thinking or altered consciousness
What is the SQUID in delirium?
Single QUestion In Delirium:
Has the person been more confused recently?
What are some differentials for delirium?
Dementia Stroke SOL Depression Non-seizure status epilepticus Wernicke's encephalopathy
What investigations would you want to do in ?delirium?
FBC, U+Es, LFTs, TFTs,
Urinalysis
CXR
ECG
CT/MRI head
ABG
Ca, B12/folate
Blood/ sputum cultures
What medications could you use in delirium management?
Lorazepam (aggression etc.)
Haloperidol in psychosis
What is the management for delirium?
Alter causes- medication, environment, infection, constipation, nutrition, electrolyte imbalance etc.
Review medications
Manage pain/ constipation/ infection/ electrolytes
Manage environment, nursing strategies, sleep hygiene, avoid moving around, include family members
Medication (if must); lorazepam, haloperidol
What is the presentation/ symptoms of dementia?
Reduced cognition Agnosia Apraxia Memory loss Visuospacial disturbances Hallucinations/ illusions Language disturbances Functional impairment
6 months
What is the pathophysiology of Alzheimer’s disease?
Brain atrophy
Reduced ACh neurotransmitters, leading to poor CNS signalling and brain atrophy–> reduced memory and cognition
Build up of B-amyloid plaques + neurofibrillary tangles
What are the macroscopic and microscopic brain findings in dementia?
Macroscopic:
- Brain atrophy
- Enlarged ventricles
Microscopic:
- decreased neurotransmitter function
- neurofibrillary tangles
- B-amyloid plaques
What is the medical management of dementia?
AChE inhibitors: donepazil, galantamine
NMDA receptor antagonists: memantine
Control risks in vascular dementia; statins, antihypertensives
In haemorrhagic stroke, what is used to reverse warfarin and heparin?
Warfarin; vitamin K
Heparin; protamine sulphate
What tool is used to assess malnutrition and what does it consider?
MUST; Malnutrition Universal Screening Tool
BMI
% weight loss
Any acute disease?
How can you manage malnutrition?
Food;
- snacks
- nutritional drinks
- food fortification/ high calorie additions
Nutritional supplements;
- liquids/ semisolids
Enteral (NG/PEG)/ parenteral (IV) nutrition
What is refeeding syndrome?
Fluid retention and cardiac arrhythmia and resp insufficiency as a result of reversing malnutrition too quickly
How do you manage refeeding syndrome?
IV Pabrinex
and gradual increase of nutrition
Regular monitoring of U+Es, fluid balances and stool chart
What is the pathophysiology of pressure ulcers?
External pressure results in reduced vascularisation, tissue compression, reduced oxygenation and nutrition
Leads to pain and increased risk of infection
What are contributing/ risk factors to pressure ulcers?
Immobility Obesity Diabetes Peripheral arterial disease Faecal or urinary incontinence Dehydration and malnutrition
How do you prevent pressure ulcers?
SSKIN
- Support pt- pressure mattresses, gel pads etc.
- Skin assessments
- Keep moving
- Incontinence and moisture management
- Nutrition and hydration management
What are the elements of advanced care planning?
- Advanced statements
- Advanced Decision of Refusal of Treatment
- Lasting Power of Attorney
What is an advanced decision of refusal of treatment?
Legally binding written statement of decisions
Comes into action when capacity is lost
What are key drugs used in end of life prescribing?
- pain
- nausea
- agitation/ hallucinations
Pain: Morphine!
Nausea: Metoclopramide or haloperidol
Antipsychotic: Haloperidol
Where can someone be discharged to?
- Home with GP/ NHS or home from hospital support ± a few weeks of domestic support
- Home with support e.g. personal/ NHS care, home adaptations, aids or palliative care
- Care home- residential or nursing
- Hospice- end of life care
