Integrated Care Flashcards
Define acute confusion
An acute deficit in thinking, short term memory and orientation to time/place with reduced awareness
Define dementia
A syndrome of progressive and global intellectual deterioration without impairment of consciousness
Memory loss is often the first symptom noted but progresses to other deficits including thinking deficits
Define delirium
Acute onset confusion with hallucinations or illusions
Give 6 common causes of delirium
Infections e.g. UTI
Constipation/urinary retention
Medications - particularly ones that increase the cholinergic burden
Post-op/surgery/reduced mobility
Metabolic causes - hypoxia, electrolyte imbalance
Dehydration!
What is meant by on/off fluctuations in patients who are taking levodopa preparations and why do they occur?
Unpredictable fluctuations in motor function due to medication “wearing off”
What is the comprehensive geriatric assessment (CGA)?
MDT diagnostic process
Aim is to determine the medical, psychological and functional capability of a frail older person
So that both an acute and long term treatment plan can be made
What are some advantages of the CGA?
People are more likely to remain active and less dependent
NNT = 17 to avoid 1 death at 6 months (NNT is low)
What is a disadvantage of the CGA?
Whole MDT has to be involved to be effective
Why may elderly patients be more prone to drug toxicity?
Kidney are worse = reduction in renal clearance
Leads to accumulation so increases chance of adverse events
Which medications should be used with particular care in the elderly?
Nephrotoxic drugs e.g. NSAIDs, ACEI, Aminoglycosides e.g. Gentamicin
Drugs that are excreted renally e.g. Digoxin
What is the effect of NSAIDs on the kidney?
Cause vasoconstriction of the AFFERENT arteriole
So can reduce perfusion by reducing blood flow in this way
What is the effect of ACEI/ARBs on they kidney?
Causes vasodilation of the EFFERENT arteriole
Reduces pressure within the vessels of the kidney = reduces perfusion
Why should co-prescribing NSAIDs and ACE inhibitors (especially in elderly) be avoided?
When effects of both drugs are taken together, the renal cortical perfusion can be significantly reduced
Can lead to significant renal impairment
Name 3 classes of drugs that have been found to increase the risk of falls in older patients
Benzos
Antidepressants
Antipsychotics
Describe the typical history associated with vasovagal syncope
Onset = seconds
Has a trigger e.g. fear, stress, pain or standing up
What are the common examination findings in a patient with vasovagal syncope?
Might have a postural drop (>20mmHg systolic or >10mmHg diastolic)
Might be normal
Describe the typical history associated with cardiac syncope
Sudden onset and recovery.
Chest pain,
Palpitations
Shortness of breath.
What are the common examination findings in a patient with cardiac syncope?
Changes in pulse - fast, slow irregular
Describe the typical history associated with a neurological fall
Rapid onset
Headache
Decreased GCS
Weakness
Altered sensation
What are the common examination findings in a patient with a neurological fall?
Focal neurology
Persistently abnormal GCS.
Describe the typical history associated with a seizure
Possible aura
No memory of fall
Abnormal limb movements
Tongue biting
Incontinence
Post-ictal phase
What is Todd’s paralysis?
Post seizure unilateral weakness that is self resolving
Describe the approach to assess someone with recurrent falls (a big one)
1) Hx and Examination
2) Drug review - GP + pharmacist
3) Medical risk factors - vision, syncope, CVS, CBS, DM
4) Functional and Mobility assessment - OT and Physio
5) Psychological effects of the fall
According to the Gold Standards framework, what 4 questions should an Advanced Care Plan address
At this time in your life, what is important to you?
What elements of care are important to you and what WOULD you like to happen in future?
What would you NOT want to happen? Is there anything that you worry about or fear happening?
Who would speak for you - your nominated proxy spokesperson or Lasting Power of Attorney?
Give 3 barriers to carers accessing support
A lack of information
Reluctance to use services because of a sense of duty
Restrictions in service use due to cost or lack of availability
Give 4 questions that you might use as part of a spiritual history?
What would be the most helpful thing for you?
What do we need to know about you to give you the best care?
Where do you get your strength from?
Is religion or faith important to you?
Define stress incontinence
Involuntary leakage of urine on effort or exertion, sneezing or coughing due to an incompetent sphincter
Define urge incontinence
Involuntary urine leakage + urgent need of micturition.
This means a sudden and compelling desire to urinate that cannot be deferred.
What is the underlying pathophysiology in urge incontinence?
In urge incontinence there is detrusor instability or hyperreflexia leading to involuntary detrusor contraction.
This may be idiopathic, secondary to neurological problems or due to local irritation e.g. infection
Define overflow incontinence
The involuntary release of urine when the bladder becomes overly full, even though the person feels no urge to urinate
Due to a weak bladder muscle or to blockage e.g. prostatic disease in men
Give 6 non-pharmacological approaches to managing constipation in adults
1) increase dietary fibre
2) Adequate fluid intake
3) Maintain mobility
4) Review toileting conditions e.g. lack of privacy, position
5) Regular toileting (gastrocolic reflex)
6) Sorbitol (a naturally occurring sugar that draws water into the lumen e.g. prunes! grapes, raspberries, apples)
Describe the pharmacological management of constipation in adults
Basically laxatives
Bulk forming = fybogel
Osmotic = Lactulose, Macrogol, Phosphate enema
Stimulant = Bisacodyl/Senna
Stool softener = Docusate
How does Fybogel work? When should caution be taken?
Bulk forming laxative
Enables fluid to be retained within faeces
More mass = more peristalsis
Need adequate fluid otherwise risk BO
Not for those taking opioids
How do Lactulose/Macrogol/Phosphate enema work? What are 3 disadvantages?
Osmotic laxative so increase amount of water in the bowel
Lactulose can worsen bloating/colic
Movicol difficult if fluid restricted
Can affect meds absorption
How does Senna work?
Stimulant laxative
Stimulates nerves that control the muscles of the GIT
How does Docusate work?
Glycerin suppository
Hyperosmotic action
Which 3 things are assessed as part of the MUST score?
BMI
Unplanned weight loss in past 6 months
Whether patient is acutely unwell
Gives overall risk of malnutrition
What counts as high risk on the MUST score and how should this be managed?
2 or more
Follow MUST 1 care pathway
Refer to dietician
Re-weigh weekly
Document action taken
What is the inverse care law?
Describes a perverse relationship between the need for health care and its actual utilisation
Those who most need medical care are least likely to receive it.
Those with least need of health care tend to use health services more (and more effectively).
What is the STOPP START tool?
Screening tools developed to identify older patients at risk from adverse effects and to reduce the risk of initiating drugs likely to cause adverse events
STOPP = 65 clinically significant criteria for potentially inappropriate prescribing in older people.
START = 22 evidence-based prescribing indicators for commonly encountered diseases in older people.
How does the absorption of Levodopa change with increasing age?
May be a significant increase in the absorption of levodopa
How may drug metabolism within the liver be affected in an elderly person?
Bioavailability may be increased due to reduction in first pass metabolism
? interactions
? metabolism problems in hepatic impairment
Give 2 examples of side effects of NSAIDs that may be more common/pronounced in elderly people
GI bleeding
Worsens HF/Renal impairment
Don’t use with ACEI
Try paracetamol instead first
Give an example of a side effect of anticoagulants that may be more common in elderly people
GI bleeding/PUD
For warfarin, prescribe only when patients have a full understanding of why the drug is being taken, its dangers, correct daily dosing/timing and the importance of regular INR monitoring.
Which Antidepressants should be avoided in the elderly and why?
Tricyclics - cause postural hypotension and confusion
Which hypoglycaemic agents should be avoided in the elderly and why?
Long-acting oral hypoglycaemics such as chlorpropamide and glibenclamide
Due to significant risk of hypoglycaemia, especially if they who live alone, have a poor understanding of diabetes self-management, or who experience few warning symptoms of hypoglycaemia.
Basically, how should you approach prescribing within the elderly population?
1) Do they really need it?
2) Start low, go slow
3) Keep it simple: use drug regimens with the lowest number of different agents and with dosing intervals of once or twice daily
4) Make what they’re taking clear, use a dosette box
5) MDT approach for support
When would a CGA be carried out?
When an older person presents to their GP with one or more obvious frailty syndromes
When a GP or community team learns of an incident which implies frailty in an individual
When an individual has been discharged from hospital after presenting with a frailty syndrome
Care Homes
Give examples of functional assessment tools
Barthel Index
Timed up and go test
Nottingham Extended Activities of Daily Living Scale
What could be some warning signs for dangerous driving in an elderly context?
Car Insurance Changes/Traffic fines e.g. caught speeding
Damage to the Car
Reluctance to drive
Driving Behavior Changes e.g. Are they aware of traffic lights, road signs, pedestrians and the reactions of other motorists? Do they react slowly or with confusion in unexpected situations?
What are the rules about driving in the elderly?
Have to renew license at 70
Have to declare medical conditions e.g. Visual loss, PD, insulin treated DM, MS
What questions could you ask to ascertain how good someone is at taking their medication?
In general:
• “Are you good at remembering your pills?”
• “Can you swallow them OK?”
• “What are you most concerned about with your tablets?”
For each medication: • “Do you take this?” • “How often?” • “What for?” • “Do you think it works?” • “Does it have any side effects?”
Why is creating a problem list helpful?
Can structure an approach to older patients with complex, multiple comorbid conditions/ conditions in need of collaboration between primary and specialist care/ those with multiple needs (e.g. socioeconomic, health, safeguarding)
What are the 4 steps to forming an effective care plan?
Prepare
Discuss
Document
Review
Give 4 examples of Simple tests for walking
and balance
Timed up and go test - functional mobility
180 degree turn test - dynamic balance
Gait speed - slow = increased risk of falling
Chair stand - using arms = less lower limb strength
What are 3 gait ref flags and who should receive a multifactorial risk assessment for falls?
- Two or more falls in the past 12 months.
- Presentation for medical attention with a fall.
- Difficulty with walking or balance.
What are 4 risk factors for delirium?
Age: over 65 years.
Pre-existing cognitive impairment or dementia
Severe illness.
Current hip fracture.
Give 5 examples of drugs that may exacerbate delirium
Cholinergic Tricyclic antidepressants e.g. amitryptilline.
Antimuscarinics e.g. oxybutynin.
Histaminergic - Antihistamines e.g. cetirizine, loratadine, hydroxyzine.
H2 receptor antagonists e.g. ranitidine
Opioids e.g. codeine.
Benzodiazepines e.g. lorazepam.
Hyoscine.
What are the 6 principals of the mental capacity act?
1) Presumption of capacity
2) Support individuals to make own decision e.g. supply with all information, translator might be needed
3) Have the right to make unwise decisions
4) Any decisions made if the individual is lacking capacity is within the best interests of the patient
5) Have to choose the least restrictive option for treatment if the individual cannot consent
6) Capacity is specific to a decision e.g. might be able to choose what to have for breakfast but not for surgery
What needs to be assessed to see if a person can make their own decisions i.e. have capacity?
Understand information given to them
Retain that information long enough to be able to make the decision
Weigh up the information available to make the decision
Communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand
Why would an advanced care plan be offered?
Planning future care and support, including medical treatment, while individuals still have the capacity to do so.
What can an advanced care plan be based on?
1) An Advance Statement. (legally binding)
2) The views of a legal proxy with powers appropriate to the decision in question. (legally binding)
3) Verbal statements made by the person before capacity was lost.
What is a power of attorney?
Someone that a person with capacity may appoint to make decisions on their behalf when they lose capacity
Can be appointed for property and financial affairs, and/or for health and welfare decisions
When can a DoLS be used?
Lack capacity + acting in their best interest, and in the least restrictive way possible.
E.g.
Medication being given against a person’s will
Staff having complete control over a patient’s
care or movements for a long period.
Staff making all decisions about a patient, including choices about assessments, treatment and visitors.
Give 2 examples of behavioural changes that may occur in Dementia
Rigid, fixed routines
Restless and purposeless activities
Give 2 examples of personality changes that may occur in Dementia
Sexual disinhibition
Blunting
Give 3 examples of speech changes that may occur in Dementia
Aphasia
Mutism
Syntax errors
Give 3 examples of thought changes that may occur in Dementia
Poor memory +/- confabulation
Slow/muddled
Lack of insight
Give 2 examples of perceptual changes that may occur in Dementia
Illusions
Hallucinations (often visual, esp with Lewy body)
Give 4 examples of types of Dementia
Alzheimers
Vascular
Lewy Body
Frontotemporal
Can also be a mixed picture
What are the 4 As of Alzheimer’s disease?
Aphasia
Amnesia
Agnosia (inability to interpret sensations and hence to recognise things e.g. can’t recognise people or sounds)
Apraxia (inability to have purposeful body movements)
What is the general trajectory of Alzheimer’s disease?
Gradual onset, progressive in nature and irreversible. The line on the graph is a gradual, downward slope
Mild = forgetful, misplace things, can’t find words, poor judgment, poor planning
Moderate = Personality changes, confusion about orientation - wandering? Difficulty in remembering personal information, sleep-wake reversal, hyperorality
Severe = Apathy, incontinent, wasting, can no longer communicate
What is the pathophysiology of Alzheimer’s disease?
Atrophy of the cerebral cortex and formation of amyloid plaques and neurofibrillary tangles.
Leads to a reduction in Acetylcholine production in affected neurones
What is the pharmacological management of Alzheimer’s disease?
Acetylcholinesterase Inhibitors can be used for mild-moderate Alzheimers (Donepezil, Rivastigmine, Galantamine)
NMDA receptor antagonists can be used for moderate - severe (Memantine) but has a lot of side effects
What are the side effects of Memantine?
Common = confusion, headaches, hallucinations
Less common = vomiting, hypertonia, anxiety
What is the definition of vascular dementia?
Cognitive impairment as a result of reduced blood supply to the brain
Usually due to large or multiple small cerebrovascular infarcts or cerebral amyloid angiopathy
How would someone with vascular dementia present?
Symptoms increase in severity in a stepwise way - so plateau then suddenly worsen and plateau again
Gait, attention problems, personality changes, ? focal neurology
What is the medical management of vascular dementia?
There isn’t any
Have to do general and symptom management
What is Dementia with Lewy bodies?
A neurodegenerative disorder characterised by cortical and subcortical Lewy bodies which are abnormal deposits of proteins inside nerve cells
What are the features of Dementia with Lewy bodies?
Similar to Parkinson’s so Parkinsonism
Repeated falls, syncope, transient LOC, visual hallucinations more common
Not really a pattern to the progression and can have periods of lucidity
How does DLB differ from Parkinson’s dementia?
Cognitive symptoms and Parkinsonism within 1 year = DLB
Parkinsons but develop dementia after 1 year = PD
What are 4 non-modifiable risk factors for developing dementia?
Age (older)
Mild cognitive impairment/Learning Difficulties e.g. Down’s syndrome (on the same chromosome)
FHx
PMH - Parkinson’s disease, stroke, depression
What are the modifiable risk factors for developing dementia?
Cardiovascular risk factors
Heavy alcohol consumption
Low socioeconomic status
Low educational attainment
Give 5 complications of dementia (remember it doesn’t just affect the individual)
Disability, dependence
Behavioural and psychological symptoms e.g. aggression, wandering
Institutionalisation i.e. loss of ability to perform ADLs leading to increased dependence and lack of appropriate care = placement in long term care
Carer morbidity!
Financial hardship
Which medical investigations should be done if someone has presented with a memory problem in order to identify reversible causes?
(8 in this list)
The works
FBC ESR U&E Ca HbA1c LFT TFT B12, folate
How would cognition be assessed in someone presenting with memory problems?
Use a cognitive assessment tool e.g. MMSE, Montreal Cognitiva Assessment (MOCA), Addenbrooks (ACE)
Have to take into account educational level, language, physical and mental health problems as may bias
How would daily functioning be assessed in someone presenting with memory problems?
Ask about personal care, housework, meal prep, finances, taking meds
Safety in and out of home
social support
Do they drive????
How would psychological state be assessed in someone presenting with memory problems?
Ask both patient and carer
Environmental issues
Depression??? could be underlying
Co-morbidities?
Give 6 differentials for ‘memory problems’
Organic - Dementia, delirium, vitamin deficiency (thiamine, B12), hypothyroidism,, normal pressure hydrocephalus
Non-organic - depression (pseudo-dementia)
When would you refer someone to specialist psychiatry if they have suspected dementia?
Likely genetic cause
LD
<65
Focal neurology
Rapid cognitive decline
When do you refer to memory clinic?
Suspected dementia
Mild cognitive impairment
What are the rules surrounding dementia and driving?
Diagnosis = LEGALLY require to inform the DVLA
Can still drive a group 1 vehicle but decision is based on medical reports
Cannot drive a group 2 e.g. bus or lorry
The license holder has to inform the DVLA themselves
What would cause someone to have their license removed if they had dementia?
Anything that makes them dangerous
Poor orientation, poor decision making, lack of insight, poor judgement
What is the doctor’s role for assessing safety when driving and the DVLA
Advise pt on impact of condition on safety when driving
Advise pt that it is their (pts) legal requirement to notify the DVLA
Manage condition with ongoing consideration of fitness to drive
When should the clinician notify the DVLA that someone is not fit to drive
If the individual cannot or will not notify the DVLA themselves
I.e. if there is a concern for road safetyt
What is important to ascertain when someone has been initially diagnosed with dementia?
Wishes for future care whilst they still have mental capacity - LPA, advanced decisions, advanced statements
What is an advanced statement vs decision
Statement = what the person wishes to be done if they lose capacity or the ability to communicate (not legally binding).
Decision = Can refuse treatment in a predefined future situation (sometimes called ‘living wills’).
What would be a holistic approach to the management of a person diagnosed with dementia?
Consider need to refer to other services e.g. SALT, OT, PT, Social
Consider non-pharmacological mx for biopsycho symptoms - exercise, aromatherapy
Moving to a safe and low stimulation environment
Monitor care giver - formal and informal support, financial essentially what they want help with
Regular review of care plan
Give 3 examples of sources of support for patients with dementia and their family
Alzheimer’s Society
RCOPsych has a good fact sheet on dementia
NHS choices
Describe the presentation of a hip dislocation vs #NOF
HD
- Posterior = Leg is shortened and internally rotated
- Anterior = Leg is lengthened and externally rotated
#NOF - Leg is shortened and externally rotated
What are the anatomical types of #NOF
Intracapsular vs extra capsular - separated by intertrochanteric line
Intracapsular = subcapital
Extracapsular = trochanteric/subtrochanteric
What is the management of a #NOF according to performance status?
Intracapsular
- Very Active/ <70/Good premorbid status = Internal fixation and fracture reduction
- Fairly active = Total hip replacement
- Not active = Hemi-arthroplasty
Extracapsular
- Dynamic hip screw
- Intermedullary nail if subtrochanteric
