Med C - Geriatrics Flashcards
What is Constipation classed as and what criteria do we use?
Constipation may involve any or all of the following (Rome IV criteria):
- Fewer than three bowel movements per week
- Hard stool in more than 25% of bowel movements
- Tenesmus (sense of incomplete evacuation) in more than 25% of bowel movements
- Excessive straining in more than 25% of bowel movements
- A need for manual evacuation of bowel movements
What are risk factors of Constipation
- Advanced age
- Inactivity
- Low calorie intake
- Low fibre diet
- Certain medications
- Female sex
Causes of constipation include:
- Dietary factors, such as inadequate fibre or fluid intake
- Behavioural factors, like inactivity or avoidance of defecation
- Electrolyte disturbances, like hypercalcaemia
- Certain drugs, particularly opiates, calcium channel blockers and some antipsychotics
- Neurological disorders, like spinal cord lesions, Parkinson’s disease, and diabetic neuropathy
- Endocrine disorders, such as hypothyroidism
- Colon diseases, like strictures or malignancies
- Anal diseases, like anal fissures or proctitis
Symptoms and signs of constipation include:
- Infrequent bowel movements (less than 3 per week)
- Difficulty passing bowel motions
- Tenesmus
- Excessive straining
- Abdominal distension
- Abdominal mass felt at the left or right lower quadrants (stool)
- Rectal bleeding
- Anal fissures
- Haemorrhoids
- Presence of hard stool or impaction on digital rectal examination
Alarm constipation features which may indicate gastrointestinal malignancy include:
Weight loss
Loss of appetite
Abdominal mass
Dark stool
The differential diagnosis for constipation includes:
- Irritable Bowel Syndrome (IBS) - characterized by abdominal pain, bloating, and alternating constipation and diarrhea
- Inflammatory Bowel Disease (IBD) - presents with abdominal pain, weight loss, and bloody diarrhea
- Anal fissures - characterized by severe anal pain during and after bowel movements, and bright red blood in the stool
- Hemorrhoids - symptoms include painless rectal bleeding, anal itching, and discomfort
- Colorectal cancer - symptoms include changes in bowel habits, rectal bleeding, and unintentional weight loss
Ix for Constipation
- Full blood count
- Electrolytes
- Thyroid function tests
- Blood glucose
- Abdominal x-ray if suspicious of a secondary cause of constipation
- Barium enema if suspicious of impaction or rectal mass
- Colonoscopy if suspicious of lower GI malignancy
Management for constipation?
- Exclusion of underlying causes including colorectal cancer
- Lifestyle modifications such as dietary improvements and increased exercise
- Enemas (e.g., sodium citrate) if impaction is present
- Suppositories such as glycerol
- Bulk laxatives such as ispaghula husk or methylcellulose
- Stool softeners like docusate sodium
- Osmotic laxatives like lactulose or macrogol
- Stimulant laxatives like senna or bisacodyl
If laxatives fail to resolve symptoms, referral to a specialist centre for evaluation of gut motility may be necessary.
What is delirium?
Delirium is an acute and fluctuating disturbance in attention and cognition, often accompanied by a change in consciousness. It is typically reversible and frequently seen in the elderly, particularly in inpatient settings.
What are the three subtypes of delirium?
- Hyperactive Delirium: Marked by increased psychomotor activity, restlessness, agitation, and hallucinations.
- Hypoactive Delirium: Characterised by lethargy, reduced responsiveness, and withdrawal.
- Mixed Delirium: Combines features of both hyperactive and hypoactive delirium.
The causes of delirium can be multifactorial and are remembered using the mnemonic DELIRIUMS:
- D: Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
- E: Eyes, ears and emotional disturbances
- L: Low Output state (Myocardial Infarction, Acute Respiratory Distress Syndrome, Pulmonary Embolism, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease)
- I: Infection
- R: Retention (of urine or stool)
- I: Ictal (related to seizure activity)
- U: Under-hydration/Under-nutrition
- M: Metabolic disorders (Electrolyte imbalance, thyroid disorders, Wernicke’s encephalopathy)
- (S): Subdural hematoma, Sleep deprivation
Delirium can present in a number of different ways, including:
- Disorientation
- Hallucinations - visual or auditory
- Inattention
- Memory problems
- Change in mood or personality. Sundowning is agitation and confusion worsening in the late afternoon or evening.
- Disturbed sleep
Patients may be hypoactive (sedated) or hyperactive (very agitated), and these presentations can fluctuate over time. Hyperactive delirium is easily seen due to the presentation, while hypoactive delirium can be easily missed as patients may appear more withdrawn.
Differentials for delirium?
- Dementia: Characterized by gradual onset, stable consciousness level, and progressive decline in cognitive function.
- Psychosis: May present with hallucinations and delusions, but usually with preserved orientation and memory.
- Depression: May exhibit poor concentration and slow cognition, but typically with a stable consciousness level and often accompanied by pervasive feelings of sadness or guilt.
- Stroke: Abrupt onset with focal neurologic signs and specific deficits in speech, motor, or sensory function.
What are common tools used for delirium?
4AT and CAM are commonly used tools for delirium assessment.
Ix for delirium?
- Bedside - bladder scan, review medications, ECG (arrhythmias, ischaemic changes that could cause hypoperfusion) urine MC&S - you should not perform urine dipstick if >65 as they are less sensitive in this age group.
- Bloods: FBC, urea and electrolyes, liver function tests, thyroid function tests, and blood cultures.
- Imaging: chest X-ray, or ultrasound of the abdomen. Neuroimaging with CT or MRI head is reserved for those without a clear identifiable cause
Management for delirium?
Management of delirium primarily focuses on treating the underlying cause. Non-pharmacological strategies should be the first line, which include:
- Providing an environment with good lighting
- Maintaining a regular sleep-wake cycle
- Regular orientation and reassurance
- Ensuring the patient’s glasses and hearing aids are used if needed
For patients who are extremely agitated and potentially a danger to themselves or others, pharmacological interventions such as small doses of haloperidol or lorazepam. Olanzapine may also be considered however, these should be used with caution, especially in the elderly, due to the risk of side effects.
What is another name for postural hypertension?
orthostatic hypotension
What is postural hypotension
Orthostatic hypotension is characterised by a decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.
The causes of orthostatic hypotension include:
- Medications, particularly vasodilators, diuretics, negative inotropes, antidepressants, and opiates
- Chronic hypertension due to the loss of baroreceptor reflexes
- Dehydration
- Sepsis
- Autonomic nervous system dysfunction, such as Parkinson’s disease
- Adrenal insufficiency
Patients with orthostatic hypotension may present with:
- Dizziness
- Syncope
- Falls
- Fractures
- More frequent occurrences after meals or exercise
- More frequent occurrences in warm environments
- Sometimes precipitated by coughing or defecating
- Symptoms can occur several minutes after standing up
Differential Diagnosis of postural hypotension?
When diagnosing orthostatic hypotension, it is essential to rule out other conditions that may cause similar symptoms. These can include:
- Vertigo: Characterized by a spinning sensation and loss of balance
- Hypoglycemia: Presents with signs such as shakiness, hunger, confusion, and sweating
- Cardiac arrhythmias: Symptoms may include palpitations, chest pain, and shortness of breath
Ix for postural hypotension?
The diagnosis of orthostatic hypotension is confirmed by a significant fall of 20mmHg or more in systolic blood pressure, or a fall of 10mmHg or more in diastolic pressure upon standing.
Management of orthostatic hypotension depends on the underlying cause and may include:
- Ensuring adequate hydration
- Evaluating polypharmacy to identify medication-related causes
- Implementing strategies to reduce adverse outcomes from falls (e.g., fall alarm, soft flooring)
- Advising behavioral changes such as rising from sitting slowly, maintaining adequate hydration
- Recommending the use of compression stockings
- Employing pharmacotherapy, including fludrocortisone and midodrine, although the evidence base for fludrocortisone is weak
Risk factors for falling
- Lower limb muscle weakness
- Previous falls
- Vision problems
- Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
- Polypharmacy (4+ medications)
- Incontinence
- > 65
- Have a fear of falling
- Depression
- Postural hypotension
- Arthritis in lower limbs
- Psychoactive drugs
- Cognitive impairment
