Older Person's Health

Question 1

What are the physiological changes that lead to food intake decline?

Answer 1

1. Decreased basal metabolic rate
2. Decreased lean body mass
3. Decreased sense of taste
4. Decreased sense of smell

Question 2

What is malnutrition?

Answer 2

is when the diet doesn’t contain the right amount of nutrients: undernutrition or over nutrition (often leading to obesity)

Question 3

How common is malnutrition?

Answer 3

experienced by around 10% of UK over 65s equal to around 1 million people

Question 4

What physical changes can put someone at risk of malnutrition?

Answer 4

1. Poor dentition
2. Swallowing difficulty
3. Arthritis and declining coordination
4. Deteriorating eyesight

Question 5

What cognitive changes and poor mental health also place people at risk can put someone at risk of malnutrition?

Answer 5

1. 22% of men and 28% of women aged over 65 experience low mood
2. Cognitive decline (plan, buying, preparing meals): ‘normal’ cognitive decline or pathological cognitive decline

Question 6

What medical conditions and medication risk malnutrition?

Answer 6

1. Medical conditions which can impair appetite include cancers, heart failure, chronic kidney disease and hypothyroidism
2. Conditions such as coeliac disease and inflammatory bowel disease can cause malabsorption syndrome
3. Medications can impair appetite e.g. some diuretics and antihypertensives

Question 7

Why can there be over nutrition in older people?

Answer 7

Physical or cognitive problems can lead to decreased activity and therefore increased weight

Question 8

Why is there a risk of malnutrition in institutionalised settings?

Answer 8

e. g. nursing homes:

- If feeding not done well this risks undernutrition

Question 9

What can malnutrition lead to?

Answer 9

1. impaired immune function
2. poor wound healing
3. osteoporosis
4. cognitive impairment
5. mood disturbances
6. joint and muscle pain

Question 10

What specific deficiencies can malnutrition lead to?

Answer 10

1. calcium
2. vitamin D
   - Both can lead to osteomalacia
3. vitamin C
   - lead to poor wound healing
4. vitamin B12
   - Folate
   - lead to anaemia
   - Reduced skeletal muscle can lead to sarcopenia

Question 11

What is important in the history for clinical assessment of nutrition?

Answer 11

• History with family and carers if the patient consents
  1. Changes to weight and BMI
  2. Additional symptoms of malnutrition
  3. Social history e.g. living situation, care needs and functional status
  4. Mental health
  5. Drug history
  6. Past medical history
  7. Food and fluid diary

Question 12

What examination is needed for the clinical assessment of nutrition?

Answer 12

1. Weight
2. BMI
3. Dentition
4. • other relevant areas e.g. dry skin, brittle nails

Question 13

What investigations are needed for the clinical assessment for nutrition?

Answer 13

1. Consider blood tests
2. Others guided by history and exam
   - Malnutrition Universal screening tool (MUST)

Question 14

What does the doctor do in the MDT for support to improve nutrition?

Answer 14

• review medication
• manage medical conditions
• co-ordinate

Question 15

What does the dietician do in the MDT for support to improve nutrition?

Answer 15

• formal nutritional assessment

- implement recommendations

Question 16

What does the occupational therapist do in the MDT for support to improve nutrition?

Answer 16

-assess and provide aids for shipping, cooking and feeding

Question 17

What does the social care professional do in the MDT for support to improve nutrition?

Answer 17

-assess and provide increased support e.g. carers, meal delivery

Question 18

What does the speech and language therapist do in the MDT for support to improve nutrition?

Answer 18

-assess swallowing and make recommendations

Question 19

What does the dentist do in the MDT for support to improve nutrition?

Answer 19

• provide comfortable dentures

- address dental problems

Question 20

What is the MDT care like?

Answer 20

Care should be holistic, strengthen relationships with family and friends and occasional exercise

Question 21

What does obstructive sleep apnoea (OSA) result from?

Answer 21

• resulting from a partial or fully blocked airway
  1. when airway becomes blocked during sleep, the brain become starved of oxygen
  2. this creates a mini arousal to reinvigorate the musculature of the airway, and this facilities a sharp intake of breath

Question 22

What is OSA often characterised by?

Answer 22

loud snoring followed by a pause in breathing and then a large gasp of air

Question 23

What is the most common primary complaint with OSA?

Answer 23

1. often unaware of these arousals from sleep

2. excessive daytime sleepiness: EDS is an increased pressure to fall asleep during normal waking hours

Question 24

Is OSA different from somnolence and fatigue?

Answer 24

1. distinct from somnolence, which is a broader term, simply meaning a strong desire to sleep, whether pathological or not
2. fatigue which refers to physical and/or mental exhaustion which does not facilitate sleep and is often not alleviated by sleep

Question 25

What are people with OSA at an increased risk of?

Answer 25

1. CVD 2. stroke 3. type 2 diabetes independent of weight or age - They also experience more serve depression - The pauses in breathing lead to hypercapnia, that is increased CO2 in the brain and so cellular death

Question 26

How is OSA diagnosed?

Answer 26

- diagnosed using PSG, this is experience and resource intensive - stop bang questionnaire provides a useful and quick tool for GP's to begin to make a differential diagnosis

Question 27

Why may the airway be blocked?

Answer 27

1. The tonsils may be too large (in which case they may be removed) 2. The jaw may be set too far back in which case you could opt for a mandibular advancement 3. Often OSA is the result of excess weight: if there is a lot of adipose tissue at the base of the tongue and around the pharynx then it is more likely the airway will collapse when the muscles are relaxed I.e. during sleep 4. So sleeping on your back is a risk factor, as is anything that impacts REM sleep

Question 28

What can increase severity of OSA?

Answer 28

- alcohol | - certain classes of antidepressants because of their impact they have on muscle tone and/or on REM sleep

Question 29

What is the treatment for OSA?

Answer 29

- Gold standard treatment for OSA is continuous positive airway pressure (CPAP) - This is a mask worn at night, the mask essentially blows air into the airway, creating a pneumatic splint - This keeps the airway open

Question 30

Is the treatment for OSA effective?

Answer 30

1. treatment itself is very effective, showing improvements in sleep, daytime, sleepiness mood and cardiovascular outcomes 2. compliance is generally very low, so often have to employ behaviours change techniques to encourage people to a where to their CPAP machines

Question 31

What lifestyle factors help to improve OSA severity?

Answer 31

1. losing weight 2. quitting smoking 3. reducing alcohol

Question 32

Who can help with the differential diagnosis of OSA?

Answer 32

- The bed partner can have important role to play in OSA diagnosis - They are the ones who will be most affected by the snoring, as the patient will be unaware of the severity of their own snoring - Asking the bed partner can be an important part of differential diagnosis when someone presents with excessive daytime sleepiness

Question 33

How common is insomnia?

Answer 33

affects roughly 10% of the population around 40% of the population will report a symptoms of insomnia at any one time

Question 34

What is the ICSD-3 diagnostic approach for insomnia?

Answer 34

1. Difficulty initiating sleep 2. Difficulty maintaining sleep 3. Waking up early than desired 4. Resistance going to bed 5. Difficulty sleeping without partner or caregiver 6. Daytime difficulties because of sleep 7. Present for 3 months to be classed as chronic: 1-3 months short-term insomnia