Introduction to geriatric medicine Flashcards
What proportion of >75s live in care homes?
7%.
You run a heart failure service. Resources are limited. There is convincing evidence that a racial group is much less likely to benefit from currently available heart failure treatments. It is reasonable to exclude this racial group from your service: true or false?
False.
You run an intensive care unit. Resources are limited. There is convincing evidence that people over 80 are much less likely to benefit from admission to intensive care units. It is reasonable to exclude this age group from your service: true or false?
False. Why does ageism not trouble us so much?
A common presentation: 90y/o lady with drowsiness and vomiting. Hx: OA, HTN, dementia. Rx: amlodipine, omeprazole. Chest clear, abdomen SNT. Severe AKI. CRP 11, urine dip WC+, nil-. Initial CT brain: age-related atrophy. Admitting doctor's plan: IVI, broad spectrum ABx, USS abdomen. AKI resolving with fluid and cessation of Rx. USS was normal. Vomiting persists. Likely underlying diagnosis and plan? a) bacterial gastroenteritis b) drug side effect c) UTI d) viral encephalitis e) viral gastroenteritis
b) drug side effect
Faecal impaction (due to amlodipine). Decisive intervention: PR examination, enema, macrogol, medication review.
What are the ‘inputs and outputs’ of balance?
Inputs: vision, vestibular (motion/rotation), joint position, muscle stretch, peripheral sensation (feet).
Outputs: skeletal muscles, eye movements, joints.
Environment: floor, lighting, obstacles, distractions.
Higher brain functions: intentions and plans, concentration, memory, confidence/fear.
What goes wrong in old people/ what are the steps of an old person deteriorating?
Age-related changes/risk => illness => reduced function/mobility=> reduced confidence=> loss of muscle/fitness => age-related changes/risk, etc- cycle
Small illness in frail person- ill and takes time to return baseline
What are the key factors predicting poor outcome from frailty?
Age, sex, smoking status.
Comorbidities, e.g. cardiorespiratory, CKD, CA.
Biomarkers (albumin, creatinine).
Function.
What is the comprehensive geriatric assessment?
Thorough geriatric history and exam, CGA works, particularly on inpatients in specialist units, and to high-risk frail patients. Acute changes vs. progression. How far from baseline? Is the new problem the main problem? Declining? Dying? What can we achieve? How can we improve QOL/ independence?
Multidisciplinary team assessment
Confusion assessment method (CAM), positive result?
What is it used for?
Acute onset AND Inattention- distractible AND Disorganised thinking- rambling? OR Altered consciousness- drowsy/ hypervigilant?
Definition of delirium [in research]- good summary of delirium
What are the consequences of delirium?
Patients with acute delirium, 1 year later: twice as likely to die, twice as likely to be in institutional care, 12x more likely to have a dementia diagnosis.
What are the causes of delirium?
20-30% of hospital inpatients.
Hypoxia.
Constipation.
Urinary retention.
Urosepsis.
Change of environment.
Withdrawal from sedatives/alcohol/analgesia.
Sedatives/alcohol/analgesia.
Anticholinergics.
What is the treatment of delirium?
Make the diagnosis, then consider cause(s).
Treat the underlying cause.
Also: supportive care, orientation, appropriate environment, stop making it worse- eg catheter, avoid immobility
What is delirium?
Acute onset change in brain function.
Serious but treatable, but recovery can be slow/incomplete.
Distractible, disorganised, drowsy/hyperalert.
Look up the CAM (and do the 4AT).
Multiple possible causes- be comprehensive.
Which of these is most suggestive of delirium?
a) AMT <7
b) agitation
c) cognitive inattention
d) positive urine dipstick
e) raised serum ammonia level
Cognitive inattention.
Which medication is most likely to cause confusion, urinary retention, and dry mouth?
a) Calcichew D3 (vitamin D supplement)
b) furosemide (loop diuretic)
c) nitrazepam (benzodiazepine)
d) oxybutynin (anticholinergic)
e) oxycodone (opioid)
d] Oxybutynin (anticholinergic).
Most common frequent presenting complaint in elderly
Falls
Confusion
Steps to present/consider a geriatric history
Background - normal health/life status/ conditions Presentation Initial assessment and diagnosis Course of treatment Current status List of problems/issues/gaps/revision Plan
Case
Background
OA, HTN, T2DM
DH: PRN paracetamol, Ramipril, benzoflumethiazide, metformin, amitryptiline
Lives alone- no family nearby
Best friend now in care home
Bifocal glasses not checked in three years
What is this lady likely to present with?
What risk factors does she have?
Fall and hip fracture
OA- stiff legs DM- Numb feet? HTN- Fluctuating BP Benzoflumethiazide- postural hypotension Amitryptilline- nerve changes
Bifocal- floor blurry
Glasses unchecked- poor vision
What is the mortality of hip fracture in the elderly like?
High
What is the pathophysiology of delirium
Not understood
Inflammatory
Neurotransmitters
Hormones
Types of delirium
Hyperactive
Hypoactive
How to tell whether dementia [chronic] or delirium [acute]?
Delirium=
- Inattentive- won’t maintain eye contact
- Drowsy/Hyperalert
- Carphologia- picking at clothes/sheets
- Not getting out of bed
- Not interacting with others
- Unwell
What percentage of people have delirium after hip fracture?
50%
95 y/old
Previously independent
Pneumonia and fall and confusion four days ago
PMH: OA, HTN
SH: Lives with son, mobile, non smoker
DH= Indapamide, Nifedipine, Nitrazepam prn
CT head- brain atrophy, small vessel disease
Normal blood tests
O2 Sats 95
Worsening confusion
Potential causes?
- Slow resolution of delirium after pneumonia
- Situational confusion - environment
- Benzodiazepine withdrawal
- Possible alcohol withdrawal
- Constipation
- Subdural haematoma- slow developing
