Older adult health and aged care Flashcards
Conditions That qualify for MBS rebate on DEXA scans
10 conditions
Premature menopause
Hypogonadism
Rheumatoid arthritis
Hyperthyroidism
Hyperparathyroidism
CKD
CLD
Coeliac or other malabsorption
Glucocorticoid use
Anti-androgen therapy
Strategies to prevent Minimal Trauma Fractures?
Implement Falls prevention
Increase weight bearing exercise 2-3 sessions a week
Balance training such as Taichi
Adequate Calcium intake
Ensure enough Vitamin D
Stop smoking
Limit alcohol to 2 SD /day
Maintain ideal body weight BMI 18-25
What is adequate calcium intake?
1300 mg in patients taking drug therapy for osteoporosis
1300 mg in women older than 50 years and men older than 70 years
1000 mg in women 50 years or younger and men 70 years or younger.
What is adequate Vitamin D intake?
Cholecalciferol 25-50 microg orally, daily
How do you prevent falls?
5 answers
Regular optometry assessment for vision
Adjusting drug therapy if possible
Minimising household risks
Providing aids for daily living
Minimising periods of immobility
How do you prevent falls?
5 answers
Regular optometry assessment for vision
Adjusting drug therapy if possible
Minimising household risks
Providing aids for daily living
Minimising periods of immobility
list causes of faecal incontinence?
(7)
Faecal impaction, can be due to low hydration, constipation, low fibre
Reduced bowel emptying- due to reduced relaxation of sphincter
Neurogenic incontinence (severe stroke or severe dementia)
Anal sphincter or pelvic muscle weakness (e.g. after surgery)
Loose bowel motions (diarrhoeal illness or change in diet)
Colorectal disease
functional issues (not enough time to reach toilet)
Important points in history taking for faecal incontinence?
- type, use a bristol stool chart
include a 7 day diary - Frequency
- Timing
- Associated symptoms
- Is there constipation, straining, or pain on defecation or local symptoms
- Effect of life/quality
- Dietary history and appetite
- Comorbidiites
- Cognitive status and mobility
Investigations for faecal incontinence?
Abdominal XRAY- to exclude faecal loading
Stool MCS and C.diff if there is no other clear cause
Colonoscopy if sinister causes suspected (may not be appropriate as holistic management in aged care)
Malabsorption syndrome screening (lactose, gluten, fat, carbohydrate) IF there seems to be a dietary association
Basic measures to help manage faecal incontinence?
(4)
Encourage regular bowel actions, say after a meal in the morning
Can be stimulated by trained professionals - massaging towards the rectum
Encourage adequate dietary fibre
and fluid intake (may take dietician). E.g bulking agents like psyllium
Promote optimisation of toilet or commode access
Advise regular exercise (within scope of comorbidities)
Medications to treat constipation include?
Stool softeners (docusate)
osmotic laxatives (lactulose)
Stimulants (senna, bisacodyl)
Suppositories (bisacodyl, gylcerine)
Severe constipation managment?
- If impacted on exam
use suppositories ASAP or micro enemas - If no impaction but history and or XRAY shows faecal loading then use oral macrogol (movicol) up to 8 sachets over 6 hours - not for more than three days in a row
- if none of the above work then consider manual dis-impaction.
Unique treatments for faecal incontinence?
(4)
surgical sphincter repair
peri anal bulking agents
sacral neuromodulation
tibial nerve stimulation
Skin care is crucial in the management of incontinence, and includes:
(4)
regular checks to ensure the skin is clean and dry
washing skin with soap-free cleanser or soap alternative
regular pad changes
application of barrier cream.
Which types of medications are particularly problematic in terms of falls?
(7)
Antidepressants
Benzodiazepines
Anti-hypertensives
Anticholinergics
Hypoglycemics (insulin, gliclazide)
Class 1A anti-arhythmic drugs (Flecanide, lidocaine)
Neuroleptics (aka first gen anti-psychotics like haloperidol)
What is important about Vitamin D in osteoporosis and falling?
- need adequate levels to optimise bisphosphonate therapy
- while it doesn’t reduce the risk of falling, it does reduce the rate of falling
In an elderly person (>65) with abdominal pain and diarrhoea what is the diagnosis not to be missed, especially if their PMH includes AF ?
Mesenteric Ischemia.
AF is a big risk factor for mesenteric ischemia as is left ventricular stasis or aneurysm.
Usually there is diarrhoea or vomiting first due to ‘gut emptying’ so don’t presume this is a viral gastroenteritis.
Causes of urinary incontinence in aged care?
DIPPERS
DIPPERS
Delirium
Infection
Pharmaceuticals
Psychological
Excess fluid
Restricted Movement
Stool impaction
What medications may affect/exacerbate the following incontinence issues in the elderly?
Stress
Urge
Chronic retention
Functional incontinence
Stress - prazosin, tamsulosin
Urge -SSRIs, anti-cholinergics, diuretics
Chronic retention- opioids, verapamil
Functional incontinence - psychotropics, analgesics
Lifestyle management for Urinary Incontinence
(list 5, there are about 10)
appropriate fluid intake
limit caffeine and alcohol
minimise evening fluid intake
treatment of constipation
regularly toileting times with good posture to encourage complete emptying
Bladder retraining in cognitively capable persons for urge incontinence
Pelvic floor exercises
Toileting assistance
Incontinence products (pads, disposable pants)
Mobility aids (beside comodes, over toilet frames)
In what vulnerability groups or situations should prompt a GP to review medications in older adults?
there is an extensive list, name at least 5.
History of falls
Recent discharge from hospital
Patients taking more than 5 regular medications
Taking > 12 doses of medication/day
Multiple chronic conditions
High risk drug groups e.g. Narrow therapeutic range
Anticholinergic load
Patients who attend multiple doctors/clinics
Confusion or dementia
What should be considered during a medication review?
- Anticholinergic load of the medications
- Try to reduce the total amount of medications
“deprescribing” - Screening for side effects particularly falls and cognitive impairment
- Review of the sedative load
- Consideration of webster packaging
What are the recommendations for exercise in older adults
Should do some form of exercise irrespective of age, weight, health problems or abilities
Be active in a variety of ways: cardiovascular fitness, strength, balance and fitness
Should incorporate at least 30 minutes of moderate intensity physical exercise every day of the week
If they have stopped exercising then to restart at a suitable level and build up gradually
What should you ask for in history if someone is deemed a higher falls risk?
Detailed history of falls that have occurred, where, how many, precipitating factors
Medications
Impaired gait?
Foot pain or deformities
home hazards
vision
incontinence
recent discharge from hospital
Chronic neurological illnesses: parkinson’s, dementia, stroke, MS
Vitamin D deficiency
What in room test can you use to help determine a high falls risk?
6 metre walk test
time it takes to sit up from chair, balance walk 3 meters and three metres back as well as sit back down
> 18 seconds indicates an increased falls risk
OR
Alternate step test
Stepping up to a 18cm high step 8 times (4 each side)
> 10 seconds indicates higher falls risk
Physical examination - what should it include in a falls assessment?
- gait
- Visual acuity
- Visual fields
- cardiac dysarrhythmias
- postural hypotension
- 6 metre walk test
- neurological impairment (limb neuro exam)
What are the exercise recommendations specifically to prevent falls
(4)
- exercise that specifically challenges balance
- needs to be done for 2 hours or more a week as a continuous lifetime activity
- Falls prevention can be home based or group based
- Walking or strength training alone (one without the other) is not sufficient to prevent against falls
Falls risk prevention activities?
(5)
- home or exercise based exercise program
If unsteady or higher risk then refer to a trained professional
- Regular medication review; anticholinergic, sedatives, psychoactive drugs and hypotensive causing agents
-consider pharmacy review - Home assessment for moderate to high falls risk by an OT
- regular optometry
- podiatrist for foot care
- manage incontinence
- Vitamin D 1000-2000 IU a day, orally
when to consider a referral for falls?
Frequency:
2+ falls in the last 12 months
Clinical features
-Unexplained falls with presyncope, dizziness or poor recall (may even get a cardiologist involved)
-Falls as part of a down spiral in physical, social and mental health
-Falls occurring as part of a low threshold (activities of daily living)
-Falls with head injury, low trauma fracture or on the floor for> 1 hour
-Gait disturbance or unsteadiness present
Prevention and early intervention activities with regards to dementia?
(8)
- Adequately address cardiovascular diseases
- exercise 150minutes moderate intensity activity a week
- Cognitive training and rehabilitation
- Social engagement (more social activities)
- Smoking cessation
- Promote the mediterranean diet
- Practice good sleep hygiene
- Reduce alcohol intake
How might you be alerted to or screen for dementia?
Form 65 years and older be alert to dementia
- Can ask “how is your memory”
- obtain history from others regarding the person:
- are they repeating questions
- are they forgetting conversations
- are they double buying/purchasing
- are there unpaid bills
- is there social withdrawal - Other cues
missed appointments (ask reception)
Change in medication compliance
Observable deterioration in grooming/dressing
What are routine tests for dementia?
FBC
ESR
CT brain
Thyroid function
B12 and folate
Calcium
LFTs
surprisingly EUC and kidney function are not included.
What are the cut off scores on MMSE for dementia?
> 24 is normal
21-24 Mild Alzheimers
10-20 Moderate Alzheimers
<10 Severe Alzheimers
what basic forms of cognitive stimulation can you offer patients?
- suduko
- crosswords
- brain teasers
- taking up new skills
What medication can be offered for Alzheimers dementia?
How is it started?
How useful is it?
Can use anti cholinesterase inhibitors.
e.g. Donepezil 4mg orally, nocte for 4 weeks then increase to 10mg, orally nocte if tolerated
also rivastigmine
These need to be started by a geriatrician initially in order to get the PBS subsidy
