GP Tutorial 1 - delirium, frailty, CGA Flashcards
1
Q
What to make clear before collateral
A
If do not have consent, make clear that cannot share any information
2
Q
Examining elderly patients
A
- Observations
- Basic obs - RR, sats, temp, BP
- Focused examination/A-E if unsure
3
Q
Why is it important to mention they may need support/changes at home early?
A
- They may take time to come around to this decision
- Ensure they do use the aids they need - often can be a mental barrier of feeling ‘old’
- Frame it as something that can give more confidence, ensure no falls and allow independence
4
Q
What should be discussed in a medication review?
A
- What medications are they taking? - bring them in, recognise them - any OTC/herbal?
- Why are they taking it? - can understand POV and can inform them if gaps
- When are you taking it? - if PRN - how many/how often
- Engage brain - interactions, changes needed based on observations
Inform them - we need to review as we may need to change some. Therefore I need to know what you are taking and why to ensure that we have it correct on the system and to treat you correctly.
5
Q
Pharmacy meds review
A
- Use STOPPSTART - aim to do in hospital to see effects, comment on in d/c summary
- Review pain relief - opioids strong - assess pain (?neuropathic, is it opioid sensitive) and review what PRNs taking. History cancer - could there be mets?
- If on laxatives - ask about bowels, are they ok? If taking opioids away may be able to remove these
- Blood pressure medications - check taking, lying and standing BP
- Naproxen + aspirin/other NSAIDs —> need PPI cover?
- Ferrous fumarate - why? was there a bleed and drop in Hb? Was this investigated?
6
Q
Good discharge planning
A
- Start thinking about it on admission - good intial social history assessment, baseline, how they normally manage
- Working with MDT - physio, OT, nurses
- Use CGA to assess needs - residential home needed? community hosp rehabilitation? package of care?
- Prevent re-admission
7
Q
Acute assessment of patient with delirium - initial
A
- Full history - establish onset of confusion and nature
- May involve collateral history
- PMH/DH/SH - establish baseline
- Cognitive screening test eg GPCOG
- Respect form?
8
Q
Precipitating factors for delirium
A
- Recent illness (cough/sore throat)
- New environment
- Medication changes
- Recent falls
- Poor oral intake
9
Q
Physical examination for someone with delirium
A
- Observe them - how do they appear
- A-E
- A/B - hypoxia? signs of chest infection? pulmonary oedema
- C - arrhythmia, murmurs, lying and standing BP
- D - glcuose (hypo?) temp, PEARL - subdural haematoma/raised ICP
- Expose - DVT? pressure sore? ulcers?
10
Q
Additional examinations to rule out delirium causes
A
- Abdo exam - retention? pain? mass?
- DRE
- Neurological exam - ?stroke/subdural haematoma
- Fluid balance asessment - dehydrated/overloaded?
- 4AT test - alertness, cognition (where, what year, who are they, date of birth) attention (months backwards) acute change?
11
Q
Confusion screen - bedside inv
A
- Basic obs - temp, BP, RR, pulse, O2 sats
- Capillary glucose - hypo?
- Lying and standing BP - postural hypotension?
- Cultures - urine, stool and sputum
- ECG - arrhythmia? MI?
12
Q
Bloods for confusion screen
A
- FBC - infection, anaemia
- U&E - electrolyte imbalance
- LFT - impaired clearance toxins?
- Bone profile - hypercalcaemia
- HbA1C
- B12/folate/iron studies
- Thyroid function tests
- CRP - infection
- Toxicology screen?
- HIV and syphillus if necessary
13
Q
Confusion screen - imaging
A
- CXR if suspect infection
- CT head without contrast if ?stroke/bleed
14
Q
Common causes of delirium
A
- Vascular - stroke/TIA/subdural haemaoma
- Infection - UTI, pneumonia, sepsis
- Trauma - to head
- Metabolic - hypoglycaemia, hyponatramia, hypercalcaemia
- Neoplastic - underlying mets –> pain or brain
- Drugs - new medications/side effects, substance withdrawal/intoxication
- Psychological - depression, new onset psychosis
15
Q
Immediate management of delirium
A
- Treat underlying cause
- Ensure safety (falls risk) monitor in quiet, well lit environment
- Re-orientate - clocks, where she is
- Manage hydration, nutrition, hearing aids/glasses
16
Q
Pharmacological interventions if agitation severe/harming others and non-pharm have not worked
A
- Haloperidol
- Lorazepam if history of Parkinsons
17
Q
Long term support of delirium
A
- Community - social services
- F/u in memory clinic if suspect dementia with acute delirium change
- GP communication - d/c summary and recommendations
18
Q
What does frailty mean?
A
- State of health
- Refers to ageing process in which there is a cummulative decline in many body systems during lifetime
- In-built reserves are reduced
- Patients are less able to cope with stressors
- Increased risk of adverse health outcomes
19
Q
How is frailty identified?
A
- PRIMSA7 questionaire - score of more than 3 = frailty
- Recognise frailty syndromes - falls, immobility, delirium, incontinence, side effects of meds
- Gait speed - more than 5s to cover 4m
- Timed up and go test (TUGT) - taking more than 10s to get up from chair, walk 3m and turn around and sit down
20
Q
Measuring fraity severity
A
- Rockwood clinical frailty scale
21
Q
Relevance of frailty at population level
A
- Risk of dramatic deterioration in physical and mental health after small event
- = increased hospital admissions, morbidity and mortality
22
Q
How can frail patients be supported in the community?
A
- CGAs - identify needs and tailor
- Social workers/community health teams - organise meal delivery, shopping assistance, befriending services
- Falls prevention - PT/OT, pharmacist meds review
- Primary care - GP reviews for chronic conditions, review polypharmacy, advanced care planning ReSPECT forms etc
- Age UK - companionship, social activities
23
Q
Inpatient support for frail patients
A
- Clinical frailty scale - identify frailty early in admission
- CGA in hospital - MDT input
- Prevent delirium - good sleep, hydration, address sensory impairments, calm environment
- Safe discharge - allow stabilisation (avoid readmission), adequate POC
- Involve family
24
Q
What should be done when patients relative requests for patient to go to care home?
A
- Assess patients wishes and capacity
- Assess need via CGA
- Explore alternatives if this isn’t suitable - POC, community nursing support, assisted living
- Social services - formal assessment, explore funding and eligibility
- Short term - temporary residental care/respite care to stabilise and re-asses
- Engage family in discussions if patient consents
- Residental care process if the chosen decision - work with social services to find appropriate home, consider financial assessments and eligibility for funding
25
What is CGA?
* Assessment for a hollistic approach to managing elderly patients
* Identifies aspect of support patient may require eg medical, social and mobility
* Patient specific
* Essential for managing frailty
26
Why are CGAs used?
* Reduce mortality
* Help with transition from hospital --> carehome/home (continuity of care)
* Reduce hospital admissions and readmissions
* Lower rates of nursing home placement --> more independence
* Reduce impact of frailty and reduce progression
* Identify risks - malnutrition, drug interactions, falls
* MDT - all aspects consdiered
* Individualised - specific to needs
27
Who is involved in CGA?
* Doctors - chronic condition management
* Pharmacists - meds review
* Nurse - risk assessments, ADLs
* Physio - mobility
* Social worker - finances, housing
* OT - evaluate needs
* Dietician
* Psychologists - mood management
* Caregivers/family/patient - what do they want/think they need
28
What is involved in PRISMA7
* Older 85
* Male
* Health problems that limit activities
* Help on a regular basis
* Health problems that require you to stay at home
* Can you count on someone close to you incase of need
* Do you use stick, walker or wheelchair to mobilise
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