o l d e r p e r s o n s

Question 1

what assessment is used in older patients

Answer 1

CGA

comprehensive geriatric assessment

Question 2

what is the CGA

Answer 2

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

Question 3

what are the domains of CGA

Answer 3

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

Question 4

what members of the MDT are involve in CGA teat

Answer 4

geriatrician, nurse specialist, occupational therapist, physiotherapist, pharmacist and others as needed (speech and language therapist, dietician)

Question 5

what are the aims of discharge planning

Answer 5

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.

Question 6

describe the role of social services in discharge planning

Answer 6

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

Question 7

what is a section 5

Answer 7

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.

Question 8

what do discharges involve

Answer 8

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

Question 9

why do discharges fail

Answer 9

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.

Question 10

questions to ask in falls history

Answer 10

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?

Question 11

lx for falls in elderly

Answer 11

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

Question 12

what is delirium

Answer 12

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.

Question 13

what are the causes of delirium

Answer 13

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.

Question 14

what is delirium associated with

Answer 14

increased mortality, prolonged hospital admission, higher complication rates, institutionalisation and increased risk of developing dementia

Question 15

what are the categories of delirium

Answer 15

Delirium can be defined as hyperactive (agitated and confused), hypoactive (withdrawn and drowsy) or mixed.

Question 16

what is dementia

Answer 16

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.

Question 17

what are the different types of dementia

Answer 17

Alzheimer's
Vascular 
Dementia with Lewy Body
Parkinson's disease with dementia 
Frontotemporal dementia 
mixed

Question 18

management of Alzheimer’s and vascualar

Answer 18

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

Question 19

features of Alzheimer’s

Answer 19

Insidious onset with slow progression.

Behavioural problems are common.

Diagnosed on clinical history but brain imaging may show disproportionate hippocampal atrophy.

Question 20

vascular dementia features

Answer 20

Second most common. Suggested by vascular risk factors. Imaging is suggestive of vascular disease. Often has a step wise progression.

Question 21

features of dementia with lewy body

Answer 21

Gradually progressive.

Prominent auditory or visual hallucinations.

Delusions are well formed and persistent.

Parkinsonism commonly present but not severe

Question 22

features of parkinson’s disease with dementia

Answer 22

Parkinson’s disease with dementia – Typical features of parkinson’s disease are present and precede confusion by over a year

Question 23

features of frontotemporal dementia

Answer 23

onset often early and have complex behavioural problems, language dysfunction may occur.

Question 24

what in functional incontinence

Answer 24

Often due to cognitive impairment or behavioural problems.

Question 25

what are the features of a complete continence examination

Answer 25

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

Question 26

medical treatment for incontinence in elderly + SE

Answer 26

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.

Question 27

describe faecal incontinence

Answer 27

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.

Question 28

what are the 2 most common causes of faecal impaction

Answer 28

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

Question 29

examinations for faecal impaction

Answer 29

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

Question 30

in faecal impaction what examination must be done

Answer 30

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.

Question 31

describe the management of faecal impaction

Answer 31

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.

Question 32

when is manual evacuation used

Answer 32

Manual evacuation is done in difficult cases and the risk of perforation is outweighed by the positive impact on patient symptoms and wellbeing.

Question 33

what is the management of chronic diarrhoea in elderly

Answer 33

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

Question 34

what are TIA’s

Answer 34

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).

Question 35

what risk assessment tool is used to assess short term risk of stroke after TIA

Answer 35

ABCS2 score

Question 36

what is the ABCD2 score

Answer 36

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.

Question 37

if pt has high risk of stroke following TIA how are they managed

Answer 37

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

Question 38

Lx for patient with TIA

Answer 38

include blood tests, carotid Doppler and a brain scan (CT or MRI). Further investigations depend on the suspected pathophysiology.

Question 39

what is the treatment of TIA

Answer 39

lifestyle modifications, treatment of hypercholesterolemia and hypertension, surgical intervention for carotid artery disease if appropriate and antiplatelets

Question 40

what is a crescendo TIA and how is it managed

Answer 40

two or more TIAs a week

should be treated as being at high risk of stroke

Question 41

what is a stroke

Answer 41

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

Question 42

what are the classifications of stoke and how is this confirmed

Answer 42

infarct or haemorrhage based on brain imaging.

Question 43

what is used to identify vascular territory involved in stroke

Answer 43

Bamford classification and with brain imaging

Question 44

what is used to find underlying aetiology of strokes

Answer 44

TOAST classification

Question 45

what is the emergency treatment of stroke

Answer 45

hrombolysis for cerebral infarct/acute
ischaemic stroke syndromes; anticoagulation reversal &/or selective
neurosurgical intervention for intracranial bleeds

Question 46

what are the types of stroke

Answer 46

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.

Question 47

what rapid tools are used to assess patent presenting with suspected stroke

Answer 47

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

Question 48

what clinical stroke assessment is used to evaluate neurological status in acute stroke patients

Answer 48

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.

Question 49

describe the management of an ischaemic stroke

Answer 49

thrombolysis with alteplase.

Question 50

management of patient with intracerebral haemorrhage

Answer 50

1. aspirin 300 mg orally if they are not dysphagic or

o aspirin 300 mg rectally or by enteral tube if they are dysphagic.

Question 51

driving after TIA or stroke

Answer 51

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

Question 52

patients with stable neurological sx from stroke or TIA who have carotid stenosis should …

Answer 52

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

Question 53

patients with severe middle cerebral artery infarction are at risk of

Answer 53

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

Question 54

scores for anticoagulation, stroke prevention

Answer 54

HASBLED
CHADSVASC2

anticoagulation now is divided into warfarin vs DOAC (Direct Oral Anti Coagulant) e.g. Apixaban, Dabigatran, Rivoraxaban, Edoxaban .

Question 55

what complex decision need to be made in stroke

Answer 55

DNAR (Do Not Attempt Resusitation) and commencing enteral feeding i.e. NG and PEG.

Question 56

what are the indications for NG or PEG use

Answer 56

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.

Question 57

end of life can be recognised in the following phases

Answer 57

Bed bound.
o Semi comatose.
o Only able to take sips of fluid. o Unable to take medicine orally

Question 58

sx seen in end of life

Answer 58

Pain
o Nausea and Vomiting o Dyspnoea
o Agitation
o Confusion
o Constipation
o Anorexia
o Terminal Secretions

Question 59

people involved in pallative care

Answer 59

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.

Question 60

what does the death certfication process involve

Answer 60

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.

Question 61

what happens after pt passes

Answer 61

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

Question 62

what does a death certificate state

Answer 62

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

Question 63

cremation paper work requires that

Answer 63

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

Question 64

when should a death be reported to a coroner

Answer 64

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.

Question 65

what is the coroner’s role

Answer 65

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.

Question 66

what is the clinical frailty scale

Answer 66

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