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OPIC > GP Tutorial 1 - delirium, frailty, CGA > Flashcards

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

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2
Q

Examining elderly patients

A
  • Observations
  • Basic obs - RR, sats, temp, BP
  • Focused examination/A-E if unsure
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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
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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.

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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?
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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
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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?
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8
Q

Precipitating factors for delirium

A
  • Recent illness (cough/sore throat)
  • New environment
  • Medication changes
  • Recent falls
  • Poor oral intake
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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?
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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?
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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?
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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
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13
Q

Confusion screen - imaging

A
  • CXR if suspect infection
  • CT head without contrast if ?stroke/bleed
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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
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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
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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
Q

What is CGA?

A
  • 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
Q

Why are CGAs used?

A
  • 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
Q

Who is involved in CGA?

A
  • 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
Q

What is involved in PRISMA7

A
  • 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
29
Q
A

OPIC (17 decks)

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