o l d e r p e r s o n s Flashcards
what assessment is used in older patients
CGA
comprehensive geriatric assessment
what is the CGA
multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up
what are the domains of CGA
Problem list – current and past
o Medication review
o Nutritional status
o Mental health – cognition, mood and anxiety, fears
o Functional capacity - basic activities of daily living , gait and balance,
activity/exercise status, instrumental activities of daily living
o Social circumstances - informal support available from family or friends,
social network such a visitors or daytime activities, eligibility for being
offered care resources
o Environment - home environment, facilities and safety within the home
environment, transport facilities ,accessibility to local resources
what members of the MDT are involve in CGA teat
geriatrician, nurse specialist, occupational therapist, physiotherapist, pharmacist and others as needed (speech and language therapist, dietician)
what are the aims of discharge planning
main aims are to reduce the person’s length of stay in hospital, to prevent an unplanned re-admission back into hospital
and to improve the manner in which community services co-ordinate following a discharge.
describe the role of social services in discharge planning
referral is made to Social Services to assess funding, for example a care home, or direct payments (the opportunity to receive a direct cash payment instead of the community care services people can use this money to buy in the personal assistance they require), or a package of care.
known as a section 2
what is a section 5
sent by nursing staff to Social Services, alerting them to the fact that the patient has been declared as ‘medically stable for discharge’.
Once the Section 5 is received, the designated social worker is expected to start taking decisive action towards discharge. Social services incur a financial penalty if they are responsible for a delayed discharge.
what do discharges involve
Medication to take home (TTO’s).
Transport.
Therapy assessment – ongoing referral to community Occupational Therapy
or Physiotherapy if required. Equipment delivery or adaptations to home if
required
Restarting package of care. – If more complex or not in place a section 2 may
be involved to arrange
Outpatient/user’s appointment.
District nurse referral if required or palliative care or community lead referral if
warranted
Transfer back letter for residential/nursing home
why do discharges fail
One or more elements of the criteria under any one title have failed e.g. obtaining a suitable package of care.
Patient/user health complications.
Communication breakdown between health care professionals and Social
Services.
Family decisions.
Decisions around funding.
questions to ask in falls history
What were they doing?
o How did the fall happen?
o How did they feel before the fall?
o Was there and dizziness or a lightheaded feeling?
o Did they lose consciousness?
o Did they have any cardiac symptoms?
o Are they weak anywhere?
o Has this happened before?
o Have they had any near misses before?
o What medication do they take? Think sedatives, cardiac medications,
anticholinergics, hypoglycaemics, opiates that can contribute to falls. o How do they normally mobilise?
lx for falls in elderly
functional assessment of their mobility – how do they mobilise, what
with and what is their gait like
o Cardiovascular examination – include an ECG and a lying and standing
BP (at immediate, 3 and 5 minutes)
o Neurological examination
o Musculoskeletal examination – assess their joints
what is delirium
is an acute confusional state, with a sudden onset and fluctuating course. It develops over 1-2 days and is recognised by a change in consciousness either hyper or hypoalert and inattention.
what are the causes of delirium
underlying medical problem, substance intoxication, substance withdrawal or a combination of those.
Infection, electrolyte imbalance, hypoxia, drugs including opiates, urinary retention, constipation and uncontrolled pain.
what is delirium associated with
increased mortality, prolonged hospital admission, higher complication rates, institutionalisation and increased risk of developing dementia
what are the categories of delirium
Delirium can be defined as hyperactive (agitated and confused), hypoactive (withdrawn and drowsy) or mixed.
what is dementia
a progressive decline in cognitive functioning usually occurring over several months. It affects many different areas of function including: Retention of new information, managing complex tasks, language and word finding difficulty, behaviour, orientation, recognition, ability to self care, and reasoning.
what are the different types of dementia
Alzheimer's Vascular Dementia with Lewy Body Parkinson's disease with dementia Frontotemporal dementia mixed
management of Alzheimer’s and vascualar
Cholinesterase inhibitors are available for the treatment of Alzheimer’s to
slow its progression, for vascular dementia there is only the ability to modify risk factors
features of Alzheimer’s
Insidious onset with slow progression.
Behavioural problems are common.
Diagnosed on clinical history but brain imaging may show disproportionate hippocampal atrophy.
vascular dementia features
Second most common. Suggested by vascular risk factors. Imaging is suggestive of vascular disease. Often has a step wise progression.
features of dementia with lewy body
Gradually progressive.
Prominent auditory or visual hallucinations.
Delusions are well formed and persistent.
Parkinsonism commonly present but not severe
features of parkinson’s disease with dementia
Parkinson’s disease with dementia – Typical features of parkinson’s disease are present and precede confusion by over a year
features of frontotemporal dementia
onset often early and have complex behavioural problems, language dysfunction may occur.
what in functional incontinence
Often due to cognitive impairment or behavioural problems.
what are the features of a complete continence examination
Review of bladder and bowel diary o Abdominal examination
o Urine dipstick and MSU
o PR examination including prostate assessment in a male
o External genitalia review particularly looking for atrophic vaginitis in
females
o A post micturition bladder scan
medical treatment for incontinence in elderly + SE
Remember that anticholinergics are not good in older people and oxybutynin whilst good for younger patients is not good for older people.
Many of the drugs used for bladder stabilisation can also cause postural hypotension leading to increased falls.
describe faecal incontinence
the body ages the rectum can become more vacuous and the anal sphincter can gape due to a number of factors including haemorrhoids and chronic constipation.
Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.
what are the 2 most common causes of faecal impaction
ost common cause of faecal incontinence is faecal impaction with overflow diarrhoea. This accounts for 50% of faecal incontinence.
The second
most common cause is neurogenic dysfunction
examinations for faecal impaction
A PR is absolutely mandatory in the assessment of faecal incontinence and
the rectum, the prostate, anal tone and sensation should all be assessed as
well as a visual inspection around the anus.
Stool type should be assessed if in the rectum
in faecal impaction what examination must be done
every full rectum is often a full bladder and if a patient is found to have urinary retention then they MUST have a PR to assess for an impacted rectum and/or a large prostate if male.
describe the management of faecal impaction
enemas for rectal loading and stool softeners and stimulants.
If stool is hard then stimulants will not help as the stool requires softening.
Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.
when is manual evacuation used
Manual evacuation is done in difficult cases and the risk of perforation is outweighed by the positive impact on patient symptoms and wellbeing.
what is the management of chronic diarrhoea in elderly
stop meds cause diarrhoea
exclude faecal impaction
regular toileting in first instance and dietary review
low dose loparemide can b trialled, and then constipating and enema regimes used
what are TIA’s
focal neurological deficits due to blockage of blood supply to a part of the brain (focal brain dysfunction) lasting less than 24 hours (but in practice most TIAs last much less than that).
what risk assessment tool is used to assess short term risk of stroke after TIA
ABCS2 score
what is the ABCD2 score
calculated by summing up the points for five different factors including age, blood pressure, clinical features, duration of symptoms and the presence of diabetes. ABCD2>=4 indicates a higher risk.
if pt has high risk of stroke following TIA how are they managed
prioritised to be seen in the TIA clinic or by a stroke physician as soon as possible. People who have had a suspected TIA should have aspirin (300 mg daily) started immediately
Lx for patient with TIA
include blood tests, carotid Doppler and a brain scan (CT or MRI). Further investigations depend on the suspected pathophysiology.
what is the treatment of TIA
lifestyle modifications, treatment of hypercholesterolemia and hypertension, surgical intervention for carotid artery disease if appropriate and antiplatelets
what is a crescendo TIA and how is it managed
two or more TIAs a week
should be treated as being at high risk of stroke
what is a stroke
as a sudden onset of a focal neurological deficit lasting more than 24 hours or with imaging evidence of brain damage due to either infarction (emboli, in situ thrombosis or low blood flow) or haemorrhage
what are the classifications of stoke and how is this confirmed
infarct or haemorrhage based on brain imaging.
what is used to identify vascular territory involved in stroke
Bamford classification and with brain imaging
what is used to find underlying aetiology of strokes
TOAST classification
what is the emergency treatment of stroke
hrombolysis for cerebral infarct/acute
ischaemic stroke syndromes; anticoagulation reversal &/or selective
neurosurgical intervention for intracranial bleeds
what are the types of stroke
TACS = total anterior circulation stroke PACS = partial anterior circulation stroke LAC = lacunar stroke POCS = posterior circulation stroke
Bamford classification is used to describe the symptoms associated with these.
TACS has the worst prognosis often leaving patients with significant weakness.
what rapid tools are used to assess patent presenting with suspected stroke
FAST = face - facial dropping, Arm - arm weakness, Speech - speech slurred, Time (time to call 999)
ROSIER = distinguish between a stroke and a stroke mimic. used in A&E
what clinical stroke assessment is used to evaluate neurological status in acute stroke patients
NIHSS = stroke scale
15 items which scores on levels of consciousness, language, neglect, visual-field loss, extra ocular movement, motor strength, ataxia, dysarthria and sensory loss.
describe the management of an ischaemic stroke
thrombolysis with alteplase.
management of patient with intracerebral haemorrhage
- aspirin 300 mg orally if they are not dysphagic or
o aspirin 300 mg rectally or by enteral tube if they are dysphagic.
driving after TIA or stroke
following a stroke or TIA you are not permitted to drive for one month. After this time you may do so as long as there are no permanent neurological sequale. If you have recurrent TIA’s you cannot drive for 3 months and you must be assessed by a doctor prior to resumption of driving
patients with stable neurological sx from stroke or TIA who have carotid stenosis should …
Be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms
o Undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms
o In both cases fitness for surgery should be assessed and there may be a small risk of stroke during surgery
patients with severe middle cerebral artery infarction are at risk of
malignant MCA syndrome and should be considered for decompressive hemicraniectomy if deterioration of clinical condition
should be referred within 24 hours of onset of symptoms and treated within a maximum of 48 hours. They must be under the age of 60, with a CT infarct of at least 50% MCA territory and an NIHSS score of above 15
scores for anticoagulation, stroke prevention
HASBLED
CHADSVASC2
anticoagulation now is divided into warfarin vs DOAC (Direct Oral Anti Coagulant) e.g. Apixaban, Dabigatran, Rivoraxaban, Edoxaban .
what complex decision need to be made in stroke
DNAR (Do Not Attempt Resusitation) and commencing enteral feeding i.e. NG and PEG.
what are the indications for NG or PEG use
indication is usually due to poor swallow following a large stroke and without it this group of patients would aspirate.
The decision to feed is often based on patient and family preference and the quality of life expected with treatment.
Even with a PEG or NG aspiration can occur and some patients will never be able to tolerate oral feeding again. NGs are often inserted post stroke when swallowing is affected and the decision to proceed with PEG feeding is often a complex decision making process involving the family and wider MDT.
end of life can be recognised in the following phases
Bed bound.
o Semi comatose.
o Only able to take sips of fluid. o Unable to take medicine orally
sx seen in end of life
Pain o Nausea and Vomiting o Dyspnoea o Agitation o Confusion o Constipation o Anorexia o Terminal Secretions
people involved in pallative care
macmillan nurses and the palliative care team can support at this stage.
Hospices and community hospital beds are available for patients who have symptoms requiring ongoing treatment or support.
The majority of patients prefer to be cared for at home.
what does the death certfication process involve
checking that pupils are fixed and dilated, that there is no response to pain and that there are no breath or heart sounds after 1 minute of auscultation.
what happens after pt passes
patient is then transferred to the mortuary and bereavement services arrange for a doctor that has cared for the patient within the last 14 days to complete the death certificate and cremation paperwork
what does a death certificate state
1a – Cause of death
o 1b – Condition leading to cause of death
o 1c – Additional condition leading to 1b
o 2 – Any contributing factors or conditions
cremation paper work requires that
2 independent doctors, one of whom has cared for the patient. Part 1 is completed by the doctor who knows the patient and part 2 by an independent doctor, two years post registration, seeking confirmation of the cause of death from a variety of sources
cremate a body pacemakers and radioactive implants must be removed
when should a death be reported to a coroner
A death should be reported to the coroner when a doctor knows or has reasonable cause to suspect that the death:
occurred as a result of poisoning, the use of a controlled drug, medicinal product, or toxic chemical;
o occurred as a result of trauma, violence or physical injury, whether inflicted intentionally or otherwise;
o is related to any treatment or procedure of a medical or similar nature; o occurred as a result of self-harm, (including a failure by the deceased person to preserve their own life) whether intentional or otherwise;
o occurred as a result of an injury or disease received during, or attributable to, the course of the person’s work;
occurred as a result of a notifiable accident, poisoning, or disease; o occurred as a result of neglect or failure of care by another person; o Was otherwise unnatural.
what is the coroner’s role
determine who died, where they died and how they died. They do not comment on care but do have powers to insisit on further local investigation. Coroners can decide to hold an inquest to ascertain the answers to the questions above.
what is the clinical frailty scale
used in dementia
proposed five frailty criteria: weakness, slow walking speed, low physical activity, self-reported exhaustion, and unintentional weight loss
check scale! make sure you know
