Medicine - Geriatrics Flashcards
What 4 domains are assessed in the comprehensive geriatric assessment?
Function and ability
Disease - severity and comorbidity
Mental health and cognition
Support networks and needs
Describe the members of the geriatric MDT and their roles:
PT - mobility, balance and limb function
OT - ADL, home environment, aids (walking aids, beds, chairs)
Dietician - nutrition
Speech and language therapist - communication, swallow screen
Social worker - care needs, discharge planning, organises institutional care
Nurses - pt education, skin care, assesses care needs before discharge, feeding, continence, communicates with relatives
Doctors - diagnosis/management of medical issues, co-ordinates assessment, plans rehab programme
Pharmacist - polypharmacy
Define a ‘fall’ in geriatrics
An unexpected event in which pt comes to rest on the ground/floor level
Is not a diagnosis in itself and must find a cause!
Describe categories of causes of falls in geriatrics
Acute illness CVS Blackouts Gait/balance Poor vision Poor cognition Vertigo Drugs Continence Psychological Environmental Mechanical/recurrent falls
Give examples of ‘Acute illness’ which could cause a fall
infection stroke sepsis HF drugs
Give examples of ‘CVS ‘ which could cause a fall
BP - orthostatic HTN
vasovagal episode
arrhythmia
structural (AS)
Give examples of ‘Blackouts’ which could cause a fall
Check BP and ECG
Give examples of ‘Gait/balance’ which could cause a fall
Neuro (DM, alcohol, folate)
Stroke/PD
Joints and feet -> muscle wasting, joints
Give examples of ‘Poor vision’ which could cause a fall
macular degeneration
glaucoma
DM
cataracts
Give examples of ‘Vertigo’ which could cause a fall
BPPV (benign positional paroxysmal vertigo)
Labyrinthitis
Give examples of ‘Drugs’ which could cause a fall
Sedatives
Abx
antihypertensives
antidepressants
Give examples of ‘Continence’ which could cause a fall
Urgency
Accidents
Immobility
Give examples of ‘Psychological’ which could cause a fall
Fear of falling -> shuffling cautious gait increases falls risk!
Give examples of ‘Environmental’ which could cause a fall
trip hazards
Give examples of ‘Mechanical/recurrent falls’ which could cause a fall
parkinsons
arthritis
stroke
Describe how falls are assessed/managed
Referral to falls clinic Nurse -> assess continence and meds, BP, ECG Physio -> neuro/muscular assessment Medical Hx and Ex Psychologist MDT!! Home assessment Minimise polypharmacy
Define urinary incontinence and its causes
involuntary loss of urine
F > M
Has stigma and embarrassment associated
Various causes: UTI, constipation, diuretics, hyperglycaemia, acute delirium
What are the 4 types of incontinence
Stress
Urge urinary
Overflow
Mixed
Describe stress incontinence and how it is managed
Weak pelvic floor muscles and intra-abdominal pressure > pelvic floor
Causes leakage when you cough/sneeze
E.g. due to childbirth/chronic coughing
Tx: conservative (exercises, reduce caffeine)
Surgery ?colosuspension
Pads
Describe urge urinary incontinence and how it is managed
An overwhelming desire to void cause not always known but can be due to: - neurological complications - small bladder capacity remember to exclude UTI/cystitis
Tx: conservative (exercises, reduce caffeine)
Pharmacological - anticholinergics, B3 agonists
Invasive - botox, sacral nerve stimulation
Pads
Describe overflow incontinence and how it is managed
A full bladder which doesn’t empty properly due to an obstruction
Dribbling, interrupted flow, straining, no warning
Causes: = BPH, MS, constipation, neurological conditions
Tx: the cause, intermittent self-catheterisation, urosheath (like a condom)
Pads
Describe mixed incontinence and how it is managed
Mix of urge and stress, Tx: pelvic floor exercises and pads
What is another way in which incontinence can be split in 2 categories:
Functional - you know you need to wee but can’t get to the toilet in time (eg arthritis, mobility issues) = the urinary / bowel systems are intact
Passive - physically you could control your bladder, but cognition is impaired (e.g. and remember that toileting is a learned behaviour)
What are complications of urinary incontinence?
Falls, fractures Social isolation Depression UTIs Skin damage
Define faecal incontinence and its causes
involuntary passage of faeces/flatus multifactorial prevalence under-recognised due to stigma causes: structural (sphincter trauma) neuro (MS/stroke) consistency altered cognition idiopathic obstetric trauma constipation
How is faecal incontinence managed?
Diet advice
Suppositories/laxatives
Antimotility agents
Surgical review ?trauma
Define delirium
Syndrome of transient reversible cognitive dysfunction which involves:
- disturbance of attention/awareness
- develops over a short time period
- fluctuates
- displays a change from baseline
Compare and contrast delirium and dementia in the following domains:
1) onset
2) course
3) conscious level
4) cognition
5) hallucinations
6) delusions
7) psychomotor
Delirium:
1) acute/subacute
2) fluctuating
3) clouded
4) memory and attention affected
5) common (visual)
6) fleeting/persecutory
7) increased/reduced activity
Dementia:
1) insidious
2) progressive
3) clear
4) any area affected, especially memory
5) usually absent
6) usually absent
7) can be normal
What are predisposing and precipitating factors in delirium?
Predisposing: male, older age, depression, dementia, alcohol, sensory impairment
Precipitating: polypharmacy, surgery, dehydration, malnutrition, sleep deprivation
What are predicting factors which cause delirium to be missed
The hypoactive subtype Older age Sensory impairment Prevalent dementia Fragility Not looking for it!
How is delirium diagnosed?
1) DSM criteria (complex)
2) CAM (confusional assessment method)
3) 4AT (includes AMT4)
4) Single Q screening tool
5) Look for abnormal hand movements:
- flocillation (plucking from the air)
- carphology (plucking at clothes)
Describe the management of delirium
Non-pharmacological: reduce RFx
- hydration, hearing aids, avoid sedatives, immobility, repeated reorientation, lights set at the correct time of day
catheter? (urinary retention may be the cause)
Pharmacological: lorazepam, antipsychiotics
(Remember the TIME bundle: triggers?, investigate, manage, engage))
Define dementia and its causes
Chronic, progressive, irreversible cognitive impairment due to brain disease
A - alzheimers V - vascular D - drugs/depression/delirium E - ethanol M - metabolic E - endocrine (DM, thyroid) N - neurological (fronto-temporal changes) T - tumour, toxin, trauma I - infection A - autoimmune
Describe alzheimers disease and its S/Sx
Gradual onset memory loss
Due to B-amyloid protein deposition in blood vessels and tau protein accumulation = neurotoxic
S/Sx: failing memory, cognitive decline, personality/mood changes, neurological abnormalities (postural changes)
Describe vascular dementia and its S/Sx
acute onset, stepwise progression, CVD risk factors
Cause of death normally pneumonia
S/Sx: Memory impairment, multiple ischaemic lesions, lack of insight
Describe lewy body dementia and its S/Sx
triad of: hallicinations, dementia, parkinsonism
accumulation of a-synuclein protein
lewy bodies then form in the dopaminergic system
S/Sx: progressive cognitive decline, fluctuating consciousness, visual hallucinations, parkinsonism
Describe fronto-temporal dementia and its S/Sx
behavioural and language changes
usually there is a FHx and younger onset
Tau protein accumulation -> causes Picks bodies to form
How is dementia investigated?
Bloods (look for reversible causes) Cultures (?infection) ECG (?vascular) SPECT scan (PD) Cognitive testing: - MMSE - Addenbrookes
What is the treatment of dementia
Non-pharmacological:
- noise/light control
- orientation
- avoid triggers (don’t move ward)
- fluid balance/diet
- early mobilisation
- limit staff changes
- recognise frailty
Pharmacological:
- antipsychotics
- benzodiazepines
What additional pharmacological treatments are available for Alzheimer’s disease?
Cholinesterase inhibitors = Donepezil (stops ACh breakdown and is thought to enhance ACh transmission and partially relieve Alzheimers symptoms)
Memantine = NMDA antagonist
Describe malnutrition and the factors involved in its development
imbalance of energy/protein/other nutrients
Causes effects on body composition, physical functioning, and clinical outcomes
Factors involved:
- catabolic state (chronic illness, acute injury)
+ other factors: difficulty accessing food, can’t cook, poor dentition…
Describe sarcopenia and the factors involved in its development
Geriatric syndrome of diminished muscle mass and function, often accompanied with unintentional weight loss
Can be primary (occurs naturally after 30yrs, and is accelerated after 60yrs) or secondary to acute illness/injury
What is used to investigate and manage malnutrition
MUST score
Swallow screen ?eating difficulties
Encourage adequate food intake
Oral nutrition supplementation
What are the 4 main classes of antidepressants
TCAs
SSRIs
Noradrenaline reuptake inhibitors
Monoamine oxidase inhibitors
What are the risk factors for osteoporosis development?
SHATTERED steroids hyperthyroid alcohol thin (low BMI) testosterone (low) early menarche renal/liver failure erosive bone disease diet (low Ca/vit D)
Describe pressure ulcers and risk factors for their development:
An area of localised skin injury, generally over a bony prominence
Occur in 30% of elderly hospitalised patients
RFx: immobility, malnutrition, sarcopenia, barrier impairment (eczema), local tissue hypoxia (DM, sepsis, PVD)
What bacteria can infect pressure ulcers if they are not elevated?
pseudomonas aeruginosa
Describe conductive causes of hearing loss
WIDENING wax/foreign body infection (otitis media/externa) drum perforation ear bone discontinuation (trauma, osteosclerosis) neoplasia INjury (high air/water pressure) Granulomatous (Wegners/sarcoid)
Describe sensorineural causes of hearing loss
DIVINITY developmental degenerative infection (meningitis, measles, mumps) vascular inflammation neoplasia injury toxins (gentamicin, furosemide) lymph (meniere's disease)
Describe elder abuse and what is may include
where there is an expected level of trust and there is repeated attacks/lack of appropriate actions causing harm/distress to an older person
5 domains: Physical Psychological Financial Sexual abuse Neglect
