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ITM 4 The Elderly Patient Flashcards

1
Q

What is the life expectancy in the UK

A

82
(Males =80
Females = 83)

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2
Q

What are the potential reasons behind an elderly person having a fall

A 
Arrhythmias 
Low BP 
Gait abnormalities 
Sensory loss 
Frailty 
Cognitive impairment 
Urinary incontinence
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3
Q

What is acopia

A

Term to describe patients who are unable to cope with activities of daily living
Often used to describe patient who don’t have acute medical problems and are deemed to be an inappropriate admission

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4
Q

What does concurrent mean

A

Presence of 2 or more medically diagnosed diseases in the same individual

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5
Q

Reasons for co morbidities

A

Increasing prevalence
Different risk factors
Increased susceptibility
Risk factors predisposing to multiple conditions
Chronic disease affecting many body systems eg T2DM

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6
Q

What are the geriatric giants

A 
Dementia 
Delirium 
Incontinence 
Depression 
Falls and dizziness 
Orthostatic hypotension 
Osteoporosis
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7
Q

What is the difference between pharmacodynamics and pharmacokinetics

A

Pharmacodynamics- the effect of the drug on the body

Pharmacokinetics- the effect of the body on the drug

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8
Q

In what ways are pharmacokinetics altered in older people

A 
Reduced 1st pass metabolism- reduced liver blood flow 
Age dependent decline in creatinine clearance 
Delayed gastric emptying 
Reduced gastric secretions 
Reduced splanchnic blood flow 
Reduced lean mass 
Increased body fat 
Decreased plasma albumin
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9
Q

Define frailty

A

A physiologic state of increased vulnerability to stressors that results from decreased physiologic reserves and dysregulation of multiple physiologic systems

Decreased reserve results in difficulty maintaining homeostasis in the face of perturbations

  • extremes of temperature
  • exacerbations of chronic disease
  • acute illness or injury eg falls, delirium
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10
Q

Define disability

A

Difficulty or dependency in carrying out activities essential to independent living including:

  • essential roles
  • tasks needed for self care
  • living independently in a home
  • desired activities important to quality of life
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11
Q

Phenotype associated with frailty

A

Shrinking (unintentional weight loss of >5% in a year)
Weakness (grip strength in lowest 20%)
Poor endurance and energy indicated by self report of exhaustion
Slowness
Low physical activity

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12
Q

What is the PRISMA 7 questionnaire

A

An assessment of frailty

1) are you older than 85
2) are you male
3) in general do you have any health problems that require you to limit your activities
4) do you need someone to help you on a regular basis
5) in general do you have any health problems that require you to stay at home
6) in case of needs can you count on someone close to you
7) do you regularly use a stick or walker to get about

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13
Q

What is the Edmonton frail scale

A

Cognitive: draw a clock
General health: no hospitalisations in past year
Functional independence: ADLs that require help
Social support: someone to count on
Nutrition: weight loss eg clothes bigger
Medications: >5 prescription meds
Mood
Continence
Functional performance: TUAG
General health: self rating

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14
Q

What is a comprehensive geriatric assessment

A

A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly persons medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow up

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15
Q

Define delirium

A

Disturbance of attention, orientation and awareness that develops within a short period of time
Presents as significant confusion or global neurocognitive impairment
Includes disturbance of behaviour and emotion and impairment in multiple cognitive domains
A disturbance in the sleep wake cycle including reduced arousal of acute onset or total sleep loss

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16
Q

Impact of delirium on the patient and family

A

Delays recovery - non complaint to treatment
Immobilisation and functional decline
Mortality
Psychological stress
Medical complications (VTE, pressure sores, aspiration and pneumonia, UTI, dehydration and malnutrition)
Care giver stress
Institutionalisation

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17
Q

Patient related risk factors for developing delirium

A 
Age >70 
Pre existing cognitive impairment 
Previous episode of delirium 
CNS disorder 
Increased BBB permeability 
Poor nutritional status 
Number and severity of comorbid illness
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18
Q

Illness related risk factors for delirium

A 
Illness severity 
Dehydration 
Infection eg UTI 
Fracture 
Hypothermia or fever 
Hypoxia 
Metabolic / electrolyte disturbances eg low sodium 
Pain 
HIV 
Organ insuffiencey
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19
Q

Environment related risk factors for delirium

A 
Social isolation 
Sensory extremes 
Visual deficit 
Hearing deficit 
Immobility 
Use of restraints 
Novel environment
Stress
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20
Q

Intervention related risk factors for delirium

A 
Peri-operative 
Type of surgery eg hip, cardiac 
Duration of operation 
Catheterisation 
Emergency procedure
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21
Q

Medication related risk factors for delirium

A 
Poly pharmacy 
Drug or alcohol dependence 
Benzodiazepine use 
Addition of >3 new medications 
Psychoactive drug use
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22
Q

Describe the cognitive function change in delirium

A 
Decreased concentration 
Slow responses 
Memory impairment 
Disorganised thinking 
Disorientation 
Reduced level of consciousness 
Shifting attention
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23
Q

Describe the physical function changes in delirium

A 
Reduced mobility 
Reduced movement 
Motor restlessness 
Agitation 
Changes in appetite 
Sleep disturbances
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24
Q

Describe the changes in social behaviour in delirium

A

Lack of cooperation with reasonable requests
Withdrawal
Alterations in communication, mood and or attitude

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25
What is the 4AT test for delirium
Assesses alertness: ask patient to state name and address AMT 4: name, age DOB, place, year Attention: months of year backwards Acute change or fluctuating course: change in alertness, function or cognition, hallucinations in past 2 weeks
26
What is appropriate poly pharmacy
- all drugs prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient - therapeutic objectives are being achieved - drug therapy has been optimised to minimise the risk of adverse drug reactions - patient is motivated and able to take all medicines as intended
27
What is inappropriate poly pharmacy
When one or more drugs are prescribed that are not or no longer needed because: - no evidence based indication or indication has expired - one or more medicine fail to achieve the therapeutic objectives they intend to achieve - one or more medicines contribute to unacceptable ADRs - patient is not willing or able to take one or more medicines as intended
28
What are the 7 steps to appropriate poly pharmacy
1) what matters to the patient: discuss medication beliefs with a patient 2) right medicine? - review medications to prevent rapid symptomatic decline 3) unnecessary medicine? Can any be replaced by lifestyle 4) effective medicine? Are therapeutic objectives being achieved 5) harmful medicine? Is the patient at risk of ADRs 6) cost effective? 7) agree and share? Is patient willing and able to take therapy as intended
29
Define dementia
A chronic or progressive syndrome that leads to disorientation in cognitive function, that is severe enough to have an impact on social or occupational function
30
What is mild cognitive impairment
Less severe than dementia Not severe enough to impact upon daily life Affects 5-20% of over 65s At increased risk of progression to dementia
31
What are the sub types of dementia
Alzheimer’s disease (50-60%) Vascular, mixed, dementia with Lewy bodies (40%) Other- frontotemporal(20% of under 65s) , alcohol related, Parkinson’s
32
What is Alzheimer’s dementia
50-60% Accumulation of B amyloid plaques in brain Tau protein hyperphosphorylation causing neurofibrillary tangles Parietal and temporal lobes most affected Acetylcholine, norepinephrine and serotonin pathways affected
33
Symptoms of Alzheimer’s dementia
Early memory loss Language problems Visuospatial problems Behavioural problems (apathy, reduced social interaction) Wandering, aggression, delusions and psychosis
34
What is vascular dementia
1-4% in over 65s Can occur due to a single cortical stroke or a number of sub cortical events which lead to cumulative deficits Typically abrupt onset and deteriorates in step wise progression
35
Symptoms of vascular dementia
Slowness of thought Personality change Frontal executive features CT scan will show evidence of vascular lesions
36
What is dementia with Lewy bodies
10-15% of dementias | Accumulation of Lewy bodies throughout brain
37
How is dementia with Lewy bodies different to Parkinson’s with Lewy bodies
In Parkinson’s disease the Lewy bodies are mainly found in the basal ganglia but in dementia they are spread throughout the brain
38
Symptoms of dementia with Lewy bodies
``` Parkinsonism Fluctuating cognitive impairment Visual hallucinations Delusions Falls Sleep disturbances ```
39
What is frontotemporal dementia
1-5% More common in age 56-61 Abnormal processing of tau protein Insidious and slow progression
40
Symptoms of frontotemporal dementia
``` Early personality changes Emotional blunting Loss of insight Inter-personal behavioural changes Memory and visuospatial ability preserved early on ```
41
How to diagnose dementia
Not a single diagnostic test Should be diagnosed by a specialist through memory assessment service Based upon history and cognitive examination
42
How to take a history when diagnosing dementia
``` Include a collateral history Ask about cognitive deficits: - memory loss - attention - language impairment - calculation - visuospatial problems - executive dysfunction ``` Behaviour changes: personality,sleep, delusions, hallucinations, continence
43
Cognitive tests used for diagnosing dementia
``` 10 point AMT MMSE MOCA Addenbrookes Clock drawing test ``` Blood tests: B12, folate, Ca, thyroid function Cerebral imaging: CT/ MRI
44
Pharmacological ways of managing dementia
Stop potentially harmful medications Cholinesterase inhibitors eg rivastigmine, donepezil (used in mild - moderate AD) Memantine - glutamate antagonist used in moderate to severe AD
45
Non pharmacological ways of managing dementia
Maximise function with daily routines and written down lists Familiar calm environment Occupational therapy Home adaptations to improve safety Education, support and rest bite for caregivers
46
What is end of life care
Helps all those with advanced, progressive, incurable illness to live as well as possible until they die Enables supportive and palliative care needs to both patient and family to be identified and met throughout the last phase of life and into bereavement
47
What factors make a good death
Treated as an individual with dignity and respect Without pain or other symptoms Familiar surroundings In the company of family or friends
48
What is the pathway to a good death
Identify people approaching end of life Initiate discussions about preferences Assess and anticipate needs, care plan and review Co-ordinate care, high quality services (pain, pharmacist, doctor, nurse) Last days of life Support for carers during and after
49
What is the purpose of advanced care planning
Used as a opportunity to lay out the values, beliefs and preferences relating to daily life through to anticipated situations - the person may wish to specify explicitly the limits of treatment
50
Management of preventing falls
Manage osteoporosis and risk of fracture
51
Risk factors for falls
``` Lower limb weakness History of falls Gait and balance problems Visual impairment Arthritis of the lower limb joints Postural hypotension Poly pharmacy Cognitive impairment Incontinence Age over 65 ```
52
Why does poly pharmacy increase risk of falls
Reflects multiple comorbidiiteis the patient has | Also drugs can interact with each other and cause problems
53
Why does incontinence increase risk of falls
Trying to get to the toilet quickly and falling over
54
Environmental factors that can cause falls
Cables Rugs that Zimmer frame can trip on Poor lighting
55
What is postural hypotension
Aka orthostatic hypotesnion | Blood pressure drop on standing
56
Common causes of postural hypotension
``` Drugs Dehydration Anaemia Sepsis Alcohol Prolonged bed rest Carotid sinus disease Autonomic failure Adrenal insufficiency ```
57
Things to notice in the PMH of someone having had a fall
Neurological conditions: previous stoke, Parkinson’s, MS (lower limb weakness), MSA Diabetes (peripheral neuropathy - associated with autonomic failure and cognitive impairment Diabetes Alcohol Arthritis of lower limbs
58
How to examine someone who has had a fall
Neurological examination Cardiovascular examination Musculoskeletal examination Injuries or complications eg fractures Gait, feet and footwear, visual acuity, cognitive assessment, hearing
59
Investigations to run after a fall
Bloods: to test for acute illness (B12- deficiency can cause degeneration of spinal cord and peripheral neuropathy, anaemia) Postural hypotension (take BP lying, sitting, standing) ECG Osteoporosis risk factors and investigations
60
What is sedentary behaviour associated with in older adults
``` Higher plasma glucose Higher BMI and waist : hip ration Higher cholesterol Reduced muscle strength Reduced bone density Frailty and falls ```
61
What 3 postural synergies do we use to maintain dynamic balance
Ankle strategy- range of movement, sensation, muscle integrity in feet Hip strategy - flexion at the hips- can be reduced with arthritis in knees or pain in hips Stepping strategy - if someone pushes you you should be able to stabilise self by taking a step
62
How can exercise reduce fall rates
Highly challenging balance training High dose (50+ hours) 3x per week Progressive strength training
63
What test is used to determine what type of dementia someone has
Addenbrookes cognitive examination III

Med 4 (12 decks)

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