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medicine for elderly > old age conditions (falls) > Flashcards

old age conditions (falls) Flashcards

1
Q

define ageing

A

progressive, generalised impairment of function resulting in a loss of adaptive response to disease

  • random molecular damage during cell replication
  • reduction in bodys adaptive reserve capacity (resilence)
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2
Q

ageing hypotheses

A
  • DNA damage affecting cell repair
  • mitochondria produce free radicals which produce oxidative stress which accumulates with age
  • tips of telomeres shorten with cell division over time leads to cell senescence
  • loss of elasticity in tendons, skins, blood vessels

hayflick limit = no. times a human cells can divide before division ceases

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3
Q

sarcopenia

A

age related loss of muscle mass, stength + muscle quality leading to decline in physical function, falls, frailty

-> reduction in type II, fast twitch, muscle fibres

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4
Q

diagnosis + management of frailty

A

diagnosis = presence of low muscle mass + either low muscle strength (hand grip) or low physical performance

Mx
- exercise - resistance training
- medication - no approved, some benefits with: growth hormone, vit D, amino acid suplements
- nutrition - promotes protein synthesis

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5
Q

frailty scoring

A

Rockwood frailty scale

  • low of homeostasis + resilience
  • increased vulnerability to decompensation after a STRESSOR EVENT
  • minor illnesses can cause profound deterioration
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6
Q

elder abuse

A
  • Some frail older adults are vulnerable to abuse
  • Usually from close relative
  • Financial, verbal, physical, sexual
  • Scale underestimated
  • 3% of over 65s report it
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7
Q

what does the comprehensive geriatric assessment comprise?

A

medical - problem list, conditions + disease severity, medication, nutrition

functioning - daily activity levels/status, gait + balance

psychological - mental status, cognitive function, mood/depression

social/environment - informal needs + assets, social circle, care resource eligibility

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8
Q

most emphasised point of comphrehensive geriatric assessment

A

problem list !!

not list of differential but most symptomatic, includes non medical issues
- weight loss, falls, confusion, polypharmacy

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9
Q

how does an MI presentation in an older person differ?

A

young -> chest pain

older
- no chest pain in 1/3
- collapse, delirium
- dizziness, breathlessness

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10
Q

how does a sepsis presentation in an older person differ?

A

BP may drop early – esp those on vasodilating antihypertensives

Tachycardiac response may be absent

Temperature often low, not high

CRP + WCC may not rise (or not much) – WCC made in bone, frail

Fluid balance may be hard – problem if low BP, or kidney problems
- Frail older people have less homeostatic reserve, they are often delicately balanced

Antibiotics should be targeted as higher risk C.Diff + antibiotic resistance

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11
Q

delirium

A

acute deterioration in mental functioning arising over hours or days that is triggered mainly by acute medical illness, surgery, trauma or drugs

disturbance in attention
change in cognition
short onset (hrs-days)
tends to FLUCTUATE

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12
Q

subtypes of delirium

A

hyperactive - agitated, agressive, wandering -> easy to diagnose

hypoactive -> withdrawn, apathetic, sleepy, coma -> easily missed, 2x the mortality rate

(be wary of drowsy “quiet” patient)

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13
Q

causes of delirium

A

DELIRIUM

Drugs/medication
Electrolyte disturbances – hyponatraemia
Lack of drugs – withdrawal
Infection
Reduced sensory input, pain
Intracranial – stroke/subdural
Urinary retention/constipation
Metabolic – AKI, hypoglycaemia, hypothyroid, B12/folate

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14
Q

delirium pathophysio

A

not well understood

  • Variable derangement of multiple neurotransmitters (particularly ACh)
  • Direct toxic insults to brain also contribute – drugs, hypoxia, low sodium, low glucose
  • Irregular stress responses probably also contribute – cortisol, prostaglandins, cytokine release
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15
Q

how does delirium differ from dementia + depression

A

sudden onset
short, flutuating course
usually reversible
agitated, restless / sleepy slow (hyper/hypoactive)
alertness FLUCTUATES
impaired attention

disorganised thinking
distorted perception (hallucinations)

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16
Q

delirium screening

A

all patients >65yrs on admission to hospital should be screened - even if asymptomatic

confusion assessment method
4-AT score

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17
Q

confusion assessment method

A

requires features of 1 + 2 and either 3 or 4

  1. acute onset + fluctuating course
  2. inattention
  3. disorganised thinking
  4. altered level of consciousness
18
Q

4-AT score

A

> =4 = possible delirium
89.7% sensitivity + 84% specificity for delirium

tests
- alertness
- AMT4 (age, DOB, current location, current year)
- attention
- acute change or fluctuating course

19
Q

delirium investigations

A

History – often collateral from fam
Full examination, neurological, MSK – may be difficult due to agitation/confusion

Blood sugar – elderly at big risk of blood sugar problems
- Medication review
- Triage any patients with high NEWS

Tests
o Bloods – FBC, U&Es, LFTs, CRP, calcium, B12/folate, TSH, Mg, glucose
o Blood cultures if septic
o ECG
o Imaging – will depend on presentation
o Bladder scan
o CT head if indicated – focal neurolgy/head injury

20
Q

common medication culprits for delirium

A

Opioids – tramadol, codeine
Anticholinergics – amitriptyline, oxybutynin
Sedatives – benzos, sleep tablets, anti-histamines
Psychotropic – lithium, anti-psychotics, anti-depressants

Anti-epileptics – phenytoin, carbamezapine
Cardiac medications – digoxin, anti-hyptensives
Steroids, NSAIDs

Withdrawal of medications/alcohol/nicotine
Parkinsons medications – NEVER stop these acutely with d/w PD specialist

21
Q

non-pharmacological management of distress/agitation in delirium

A

encourage mobilisation
optimise chronic disease
activity charts - useful if prolonged
sensory input important - glasses, hearing aids ok
fluid chart - dehydration will exacerbate

22
Q

capacity considerations in delirium

A

may have capacity for personal care but not medication decisions
adults with incapacity (AWI) form should be completed if appropriate
- review regularly, can be revoked post-delirium

initiate TIME bundle
- Think + exclude possible triggers
- Investigate _ intervene to correct underlying cause
- Management plan
- Engage + explore

23
Q

pharmacological management of distress/agitation in delirium

A

1st line = haloperidol 500mg - IM if unable to take orally
DO NOT USE IN PARKINSONS OR LEWY BODY DEMENTIA
-> in these patients use lorazepam 500mg

if requiring ongoing antipsychotic then early referral to POA is v important

(reserved when non-pharma failed + symptoms threaten safety or to others - significantly distressing psychotic symptoms)

24
Q

preventing delirium

A
  • Minimal moves in hospital, regular orientation, glasses + hearing aids
  • Maintaining oral hygiene, nutrition/hydration
  • Medication should be reviewed on admission
  • Pain control post-op + early recognition of post-op complications
  • Early mobilisations
  • Regular review of bladder/bowel function
25
Q

falls

A

Prevalence increases with age, 50% of over 80s fall at least one a year
o 3 fold higher incidence in care-home residents

Majority of falls are multifactorial
- Significant burden to patient + NHS

Assessment + management of a patient presenting with falls needs to be multifactorial

26
Q

falls

A

Prevalence increases with age, 50% of over 80s fall at least one a year
o 3 fold higher incidence in care-home residents

Majority of falls are multifactorial
- Significant burden to patient + NHS

Assessment + management of a patient presenting with falls needs to be multifactorial

27
Q

implication of falls

A

40-60% suffer injury
5% result in fracture or hospitalisation
- (hip fracture mortality 1yr post op = 15-36%

loss of confidencce -> social isolation -> functional decline

costs NHS 2.3billion a year
40% of hospital admissions

28
Q

why are old people more likely to fall?

A

motor coordination
central processing + cognition - decrease reaction time

sarcopenia
decreased cardioresp fitness
vision - smaller pupils lens thickening (decrease light)

decrease peripheral sensation + proprioception - increase postural sway

fear of falling increases risk of falls - restricts physical activity -> unconditioned balance skills

29
Q

intrinsic factors contributing to falls

A

age related changes in gait, postural reflexes, muscle strength
cognition
impaired vision + hearing
medical conditions
- diabetes -> diabetic neuropathy -> altered proprioception + poor vision
- arthritis, parkinsons, stroke -> altered gait pattern
- incontinence -> increase need to rush, mobilised at night
- acute illness -> almost anything

30
Q

extrinsic factors contributing to falls

A

medications - diuretics, antihypertensives, sedatives, anticholinergics, hypoglycaemic agents

environmental - rugs, stairs
inadequate lighting
inappropriate footwear
inappropriate use of walking aids

31
Q

vision problems associated with falls

A

Early cataract surgery reduces falls

Bifocal + varifocal glasses are assoc with INCREASED falls risk

Recent optician visit/new prescription glasses INCREASE fall risk

*ask about vision distortion – age-related macular degeneration
-> “misjudging curb…”, central vision distortion of doorframes + curbs

32
Q

when is rombergs test positive

A

in proprioceptive + vestibular disorders

loss of balance when eyes shut (feet together)

33
Q

functionally significant peripheral neuropathy

A

loss of heel reflexes
decreased vibratory sense that improves proximally
impaired sense at great toe
inability to maintain unipedal stance for 10secs in 3 attempts

(possible causes - diabetes, alcohol, vit B12 deficiency)

34
Q

“drop attack”

A

an event whereby the person suddenly collapses without any preceding symptoms + without apparent loss of consciousness

-> Account for 20% of elderly patients presenting to falls services

35
Q

orthostatic hypotension diagnosis

A

based largerly off history of symptoms + a drop >20/10mmHg within 3 mins of standing

36
Q

causes of orthostatic hypotension

A

baroreflex dysfunction - loss of baroceptor sensitivity + vasoconstriction associated with ageing (+vascular disease)

medication or other circumstances - volume depletion, immobility, alpha-blockers (BPH)

conditions that cause peripheral neuropathy can cause autonomic neuropathy + orthostatic hypotension

parkinsons + LBD

37
Q

management of orthostatic hypotension

A

stop culprit drugs - alpha-blockers (doxasin+tamsulosin), antihypertensives, diuretics, pregabilin, antidepressants

avoid sudden changes in movement
increase salt in diet
compression stocking
elevate legs
calf muscle exercises

** when failed -> fludrocortinsone, midodrine **

38
Q

psychotropic drugs that contribute to fall risk

A

taking doubles fall risk, stopping reduces fall risk

some cause orthostatic hypotension - venlafaxine, duloxetine, risperidone, haloperidol

phenytoin may cause permanent cerbellar damage + unsteadinessin long term use at therapeutic dose

39
Q

cardiac medications which contribute to fall risk

A

alpha-blockers
- used for prostatism
- doxazosin, indoramin, tamsulosin, prazosin

ACEi + betablockers should be maintained whenever poss

NICE =
- stop nitrates, CCB or other vasodilators - always check BP
- if no evidence of congestion - reduce diuretics

40
Q

what BP in old is assoc with increased fall risk?

A

BP of 120 or below

41
Q

target BPs in over/under 80s

A

over 80 = <150/90

under 80 = <140/90

medicine for elderly (4 decks)

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