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Med 4 > ITM 4 The Elderly Patient > Flashcards

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
Q

What is the 4AT test for delirium

A

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

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26
Q

What is appropriate poly pharmacy

A
  • 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
Q

What is inappropriate poly pharmacy

A

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
Q

What are the 7 steps to appropriate poly pharmacy

A

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
Q

Define dementia

A

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
Q

What is mild cognitive impairment

A

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
Q

What are the sub types of dementia

A

Alzheimer’s disease (50-60%)
Vascular, mixed, dementia with Lewy bodies (40%)
Other- frontotemporal(20% of under 65s) , alcohol related, Parkinson’s

32
Q

What is Alzheimer’s dementia

A

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
Q

Symptoms of Alzheimer’s dementia

A

Early memory loss
Language problems
Visuospatial problems
Behavioural problems (apathy, reduced social interaction)
Wandering, aggression, delusions and psychosis

34
Q

What is vascular dementia

A

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
Q

Symptoms of vascular dementia

A

Slowness of thought
Personality change
Frontal executive features
CT scan will show evidence of vascular lesions

36
Q

What is dementia with Lewy bodies

A

10-15% of dementias

Accumulation of Lewy bodies throughout brain

37
Q

How is dementia with Lewy bodies different to Parkinson’s with Lewy bodies

A

In Parkinson’s disease the Lewy bodies are mainly found in the basal ganglia but in dementia they are spread throughout the brain

38
Q

Symptoms of dementia with Lewy bodies

A 
Parkinsonism 
Fluctuating cognitive impairment 
Visual hallucinations 
Delusions 
Falls 
Sleep disturbances
39
Q

What is frontotemporal dementia

A

1-5%
More common in age 56-61
Abnormal processing of tau protein
Insidious and slow progression

40
Q

Symptoms of frontotemporal dementia

A 
Early personality changes 
Emotional blunting 
Loss of insight 
Inter-personal behavioural changes 
Memory and visuospatial ability preserved early on
41
Q

How to diagnose dementia

A

Not a single diagnostic test
Should be diagnosed by a specialist through memory assessment service
Based upon history and cognitive examination

42
Q

How to take a history when diagnosing dementia

A 
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
Q

Cognitive tests used for diagnosing dementia

A 
10 point AMT 
MMSE 
MOCA 
Addenbrookes 
Clock drawing test

Blood tests: B12, folate, Ca, thyroid function
Cerebral imaging: CT/ MRI

44
Q

Pharmacological ways of managing dementia

A

Stop potentially harmful medications
Cholinesterase inhibitors eg rivastigmine, donepezil (used in mild - moderate AD)

Memantine - glutamate antagonist used in moderate to severe AD

45
Q

Non pharmacological ways of managing dementia

A

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
Q

What is end of life care

A

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
Q

What factors make a good death

A

Treated as an individual with dignity and respect

Without pain or other symptoms

Familiar surroundings

In the company of family or friends

48
Q

What is the pathway to a good death

A

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
Q

What is the purpose of advanced care planning

A

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
Q

Management of preventing falls

A

Manage osteoporosis and risk of fracture

51
Q

Risk factors for falls

A 
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
Q

Why does poly pharmacy increase risk of falls

A

Reflects multiple comorbidiiteis the patient has

Also drugs can interact with each other and cause problems

53
Q

Why does incontinence increase risk of falls

A

Trying to get to the toilet quickly and falling over

54
Q

Environmental factors that can cause falls

A

Cables
Rugs that Zimmer frame can trip on
Poor lighting

55
Q

What is postural hypotension

A

Aka orthostatic hypotesnion

Blood pressure drop on standing

56
Q

Common causes of postural hypotension

A 
Drugs 
Dehydration 
Anaemia 
Sepsis 
Alcohol 
Prolonged bed rest 
Carotid sinus disease 
Autonomic failure 
Adrenal insufficiency
57
Q

Things to notice in the PMH of someone having had a fall

A

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
Q

How to examine someone who has had a fall

A

Neurological examination
Cardiovascular examination
Musculoskeletal examination
Injuries or complications eg fractures

Gait, feet and footwear, visual acuity, cognitive assessment, hearing

59
Q

Investigations to run after a fall

A

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
Q

What is sedentary behaviour associated with in older adults

A 
Higher plasma glucose 
Higher BMI and waist : hip ration 
Higher cholesterol 
Reduced muscle strength 
Reduced bone density 
Frailty and falls
61
Q

What 3 postural synergies do we use to maintain dynamic balance

A

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
Q

How can exercise reduce fall rates

A

Highly challenging balance training
High dose (50+ hours)
3x per week
Progressive strength training

63
Q

What test is used to determine what type of dementia someone has

A

Addenbrookes cognitive examination III

Med 4 (12 decks)

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