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EOY4 > Integrated Care > Flashcards

Integrated Care Flashcards

1
Q

Define acute confusion

A

An acute deficit in thinking, short term memory and orientation to time/place with reduced awareness

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2
Q

Define dementia

A

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

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3
Q

Define delirium

A

Acute onset confusion with hallucinations or illusions

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4
Q

Give 6 common causes of delirium

A

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!

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5
Q

What is meant by on/off fluctuations in patients who are taking levodopa preparations and why do they occur?

A

Unpredictable fluctuations in motor function due to medication “wearing off”

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6
Q

What is the comprehensive geriatric assessment (CGA)?

A

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

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7
Q

What are some advantages of the CGA?

A

People are more likely to remain active and less dependent

NNT = 17 to avoid 1 death at 6 months (NNT is low)

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8
Q

What is a disadvantage of the CGA?

A

Whole MDT has to be involved to be effective

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9
Q

Why may elderly patients be more prone to drug toxicity?

A

Kidney are worse = reduction in renal clearance

Leads to accumulation so increases chance of adverse events

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10
Q

Which medications should be used with particular care in the elderly?

A

Nephrotoxic drugs e.g. NSAIDs, ACEI, Aminoglycosides e.g. Gentamicin

Drugs that are excreted renally e.g. Digoxin

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11
Q

What is the effect of NSAIDs on the kidney?

A

Cause vasoconstriction of the AFFERENT arteriole

So can reduce perfusion by reducing blood flow in this way

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12
Q

What is the effect of ACEI/ARBs on they kidney?

A

Causes vasodilation of the EFFERENT arteriole

Reduces pressure within the vessels of the kidney = reduces perfusion

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13
Q

Why should co-prescribing NSAIDs and ACE inhibitors (especially in elderly) be avoided?

A

When effects of both drugs are taken together, the renal cortical perfusion can be significantly reduced

Can lead to significant renal impairment

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14
Q

Name 3 classes of drugs that have been found to increase the risk of falls in older patients

A

Benzos

Antidepressants

Antipsychotics

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15
Q

Describe the typical history associated with vasovagal syncope

A

Onset = seconds

Has a trigger e.g. fear, stress, pain or standing up

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16
Q

What are the common examination findings in a patient with vasovagal syncope?

A

Might have a postural drop (>20mmHg systolic or >10mmHg diastolic)

Might be normal

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17
Q

Describe the typical history associated with cardiac syncope

A

Sudden onset and recovery.

Chest pain,

Palpitations

Shortness of breath.

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18
Q

What are the common examination findings in a patient with cardiac syncope?

A

Changes in pulse - fast, slow irregular

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19
Q

Describe the typical history associated with a neurological fall

A

Rapid onset

Headache

Decreased GCS

Weakness

Altered sensation

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20
Q

What are the common examination findings in a patient with a neurological fall?

A

Focal neurology

Persistently abnormal GCS.

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21
Q

Describe the typical history associated with a seizure

A

Possible aura

No memory of fall

Abnormal limb movements

Tongue biting

Incontinence

Post-ictal phase

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22
Q

What is Todd’s paralysis?

A

Post seizure unilateral weakness that is self resolving

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23
Q

Describe the approach to assess someone with recurrent falls (a big one)

A

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

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24
Q

According to the Gold Standards framework, what 4 questions should an Advanced Care Plan address

A

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?

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25
Q

Give 3 barriers to carers accessing support

A

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

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26
Q

Give 4 questions that you might use as part of a spiritual history?

A

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?

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27
Q

Define stress incontinence

A

Involuntary leakage of urine on effort or exertion, sneezing or coughing due to an incompetent sphincter

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28
Q

Define urge incontinence

A

Involuntary urine leakage + urgent need of micturition.

This means a sudden and compelling desire to urinate that cannot be deferred.

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29
Q

What is the underlying pathophysiology in urge incontinence?

A

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

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30
Q

Define overflow incontinence

A

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

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31
Q

Give 6 non-pharmacological approaches to managing constipation in adults

A

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)

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32
Q

Describe the pharmacological management of constipation in adults

A

Basically laxatives

Bulk forming = fybogel
Osmotic = Lactulose, Macrogol, Phosphate enema

Stimulant = Bisacodyl/Senna

Stool softener = Docusate

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33
Q

How does Fybogel work? When should caution be taken?

A

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

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34
Q

How do Lactulose/Macrogol/Phosphate enema work? What are 3 disadvantages?

A

Osmotic laxative so increase amount of water in the bowel

Lactulose can worsen bloating/colic

Movicol difficult if fluid restricted

Can affect meds absorption

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35
Q

How does Senna work?

A

Stimulant laxative

Stimulates nerves that control the muscles of the GIT

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36
Q

How does Docusate work?

A

Glycerin suppository

Hyperosmotic action

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37
Q

Which 3 things are assessed as part of the MUST score?

A

BMI

Unplanned weight loss in past 6 months

Whether patient is acutely unwell

Gives overall risk of malnutrition

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38
Q

What counts as high risk on the MUST score and how should this be managed?

A

2 or more

Follow MUST 1 care pathway

Refer to dietician

Re-weigh weekly

Document action taken

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39
Q

What is the inverse care law?

A

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).

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40
Q

What is the STOPP START tool?

A

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.

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41
Q

How does the absorption of Levodopa change with increasing age?

A

May be a significant increase in the absorption of levodopa

42
Q

How may drug metabolism within the liver be affected in an elderly person?

A

Bioavailability may be increased due to reduction in first pass metabolism

? interactions

? metabolism problems in hepatic impairment

43
Q

Give 2 examples of side effects of NSAIDs that may be more common/pronounced in elderly people

A

GI bleeding

Worsens HF/Renal impairment

Don’t use with ACEI

Try paracetamol instead first

44
Q

Give an example of a side effect of anticoagulants that may be more common in elderly people

A

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.

45
Q

Which Antidepressants should be avoided in the elderly and why?

A

Tricyclics - cause postural hypotension and confusion

46
Q

Which hypoglycaemic agents should be avoided in the elderly and why?

A

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.

47
Q

Basically, how should you approach prescribing within the elderly population?

A

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

48
Q

When would a CGA be carried out?

A

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

49
Q

Give examples of functional assessment tools

A

Barthel Index

Timed up and go test

Nottingham Extended Activities of Daily Living Scale

50
Q

What could be some warning signs for dangerous driving in an elderly context?

A

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?

51
Q

What are the rules about driving in the elderly?

A

Have to renew license at 70

Have to declare medical conditions e.g. Visual loss, PD, insulin treated DM, MS

52
Q

What questions could you ask to ascertain how good someone is at taking their medication?

A

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?”
53
Q

Why is creating a problem list helpful?

A

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)

54
Q

What are the 4 steps to forming an effective care plan?

A

Prepare

Discuss

Document

Review

55
Q

Give 4 examples of Simple tests for walking

and balance

A

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

56
Q

What are 3 gait ref flags and who should receive a multifactorial risk assessment for falls?

A
  • Two or more falls in the past 12 months.
  • Presentation for medical attention with a fall.
  • Difficulty with walking or balance.
57
Q

What are 4 risk factors for delirium?

A

Age: over 65 years.

Pre-existing cognitive impairment or dementia

Severe illness.

Current hip fracture.

58
Q

Give 5 examples of drugs that may exacerbate delirium

A

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.

59
Q

What are the 6 principals of the mental capacity act?

A

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

60
Q

What needs to be assessed to see if a person can make their own decisions i.e. have capacity?

A

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

61
Q

Why would an advanced care plan be offered?

A

Planning future care and support, including medical treatment, while individuals still have the capacity to do so.

62
Q

What can an advanced care plan be based on?

A

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.

63
Q

What is a power of attorney?

A

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

64
Q

When can a DoLS be used?

A

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.

65
Q

Give 2 examples of behavioural changes that may occur in Dementia

A

Rigid, fixed routines

Restless and purposeless activities

66
Q

Give 2 examples of personality changes that may occur in Dementia

A

Sexual disinhibition

Blunting

67
Q

Give 3 examples of speech changes that may occur in Dementia

A

Aphasia

Mutism

Syntax errors

68
Q

Give 3 examples of thought changes that may occur in Dementia

A

Poor memory +/- confabulation

Slow/muddled

Lack of insight

69
Q

Give 2 examples of perceptual changes that may occur in Dementia

A

Illusions

Hallucinations (often visual, esp with Lewy body)

70
Q

Give 4 examples of types of Dementia

A

Alzheimers

Vascular

Lewy Body

Frontotemporal

Can also be a mixed picture

71
Q

What are the 4 As of Alzheimer’s disease?

A

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)

72
Q

What is the general trajectory of Alzheimer’s disease?

A

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

73
Q

What is the pathophysiology of Alzheimer’s disease?

A

Atrophy of the cerebral cortex and formation of amyloid plaques and neurofibrillary tangles.

Leads to a reduction in Acetylcholine production in affected neurones

74
Q

What is the pharmacological management of Alzheimer’s disease?

A

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

75
Q

What are the side effects of Memantine?

A

Common = confusion, headaches, hallucinations

Less common = vomiting, hypertonia, anxiety

76
Q

What is the definition of vascular dementia?

A

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

77
Q

How would someone with vascular dementia present?

A

Symptoms increase in severity in a stepwise way - so plateau then suddenly worsen and plateau again

Gait, attention problems, personality changes, ? focal neurology

78
Q

What is the medical management of vascular dementia?

A

There isn’t any

Have to do general and symptom management

79
Q

What is Dementia with Lewy bodies?

A

A neurodegenerative disorder characterised by cortical and subcortical Lewy bodies which are abnormal deposits of proteins inside nerve cells

80
Q

What are the features of Dementia with Lewy bodies?

A

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

81
Q

How does DLB differ from Parkinson’s dementia?

A

Cognitive symptoms and Parkinsonism within 1 year = DLB

Parkinsons but develop dementia after 1 year = PD

82
Q

What are 4 non-modifiable risk factors for developing dementia?

A

Age (older)

Mild cognitive impairment/Learning Difficulties e.g. Down’s syndrome (on the same chromosome)

FHx

PMH - Parkinson’s disease, stroke, depression

83
Q

What are the modifiable risk factors for developing dementia?

A

Cardiovascular risk factors

Heavy alcohol consumption

Low socioeconomic status

Low educational attainment

84
Q

Give 5 complications of dementia (remember it doesn’t just affect the individual)

A

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

85
Q

Which medical investigations should be done if someone has presented with a memory problem in order to identify reversible causes?

(8 in this list)

A

The works

FBC
ESR
U&E
Ca
HbA1c
LFT
TFT
B12, folate
86
Q

How would cognition be assessed in someone presenting with memory problems?

A

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

87
Q

How would daily functioning be assessed in someone presenting with memory problems?

A

Ask about personal care, housework, meal prep, finances, taking meds

Safety in and out of home

social support

Do they drive????

88
Q

How would psychological state be assessed in someone presenting with memory problems?

A

Ask both patient and carer

Environmental issues

Depression??? could be underlying

Co-morbidities?

89
Q

Give 6 differentials for ‘memory problems’

A

Organic - Dementia, delirium, vitamin deficiency (thiamine, B12), hypothyroidism,, normal pressure hydrocephalus

Non-organic - depression (pseudo-dementia)

90
Q

When would you refer someone to specialist psychiatry if they have suspected dementia?

A

Likely genetic cause

LD

<65

Focal neurology

Rapid cognitive decline

91
Q

When do you refer to memory clinic?

A

Suspected dementia

Mild cognitive impairment

92
Q

What are the rules surrounding dementia and driving?

A

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

93
Q

What would cause someone to have their license removed if they had dementia?

A

Anything that makes them dangerous

Poor orientation, poor decision making, lack of insight, poor judgement

94
Q

What is the doctor’s role for assessing safety when driving and the DVLA

A

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

95
Q

When should the clinician notify the DVLA that someone is not fit to drive

A

If the individual cannot or will not notify the DVLA themselves

I.e. if there is a concern for road safetyt

96
Q

What is important to ascertain when someone has been initially diagnosed with dementia?

A

Wishes for future care whilst they still have mental capacity - LPA, advanced decisions, advanced statements

97
Q

What is an advanced statement vs decision

A

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’).

98
Q

What would be a holistic approach to the management of a person diagnosed with dementia?

A

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

99
Q

Give 3 examples of sources of support for patients with dementia and their family

A

Alzheimer’s Society

RCOPsych has a good fact sheet on dementia

NHS choices

100
Q

Describe the presentation of a hip dislocation vs #NOF

A

HD

  • Posterior = Leg is shortened and internally rotated
  • Anterior = Leg is lengthened and externally rotated
#NOF
- Leg is shortened and externally rotated
101
Q

What are the anatomical types of #NOF

A

Intracapsular vs extra capsular - separated by intertrochanteric line

Intracapsular = subcapital

Extracapsular = trochanteric/subtrochanteric

102
Q

What is the management of a #NOF according to performance status?

A

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

EOY4 (22 decks)

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