Older Person's Medicine Flashcards
What do the domains of a comprahensive geriatric assesment include?
Problem list- current and past Medication review Nutritional status Funcational capacity Social circumstances Environment
What is a 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 intergrated plan for treatment and follow-up.
What do the numerical values of the clinical frailty score indicate?
1 Very fit
2 Well
3 Managing well (not active beyond routine walking)
4 Vulnerable (not dependent on other but symptoms limit activities)
5 Mildly frail (need help in high order IADLs)
6 Moderately frail (requiring help with all outside activities, minimal assistance with ADLs)
7 Severely frail - dependent on others for personal care
8 Very severely frail - completely dependent on othersm approaching end of life)
9 Terminally Ill (<6 months life expectancy)
What is frailty?
Distinctive health state in which multiple body systems gradually lose their inbuilt reserves and this group of people are at higher risk of adverse health outcomes.
How many drugs prescribed at any one time constitutes ‘polypharmacy’?
6 or more
What tool can be utilised during a medication review, particularly when perforoming a CGA?
STOPP/START tool
What are the 4 criteria for capacity?
- able to understand the information
- able to retain the information given
- able to use this information to make their decision
- able to communicate this decision back
How can capacity be maxamised?
Discuss the options in a time and place that helps them to understand and remember what you say.
Ask whether having a friend or relative with them might help them to remember information, or otherwise help them make the decision.
Offer written or audio information if it will help.
Speak to the patient’s relatives, friends, and others in the healthcare team, about how best to communicate with the patient.
What are the signs that a patient is reaching the end of their life?
Bedbound
Unable to swallow medication
Unable to take sips of water
Semi-comatose state
What symptoms may a patient experience at the end of their life?
Pain Nausea and vomiting Dysponea Adgitation Confusion Terminal Secretions Constipation Anorexia
What are common anticipatory end of life medications?
Medicine for pain – an appropriate opioid, for example, morphine, diamorphine, oxycodone or alfentanil.
Medicine for breathlessness – midazolam or an opioid.
Medicine for anxiety – midazolam.
Medicine for delirium or agitation – haloperidol, levomepromazine, midazolam or phenobarbital.
Medicine for nausea and vomiting – cyclizine, metoclopramide, haloperidol or levomepromazine.
Medicine for noisy chest secretions – hyoscine hydrobromide or glycopyrronium.
What is a ReSPECT form?
Recommended Summary Plan for Emergency Care and Treatment
What is delirium?
Acute confusional state, with a sudden onset and fluctuating course.
May be hypoactive or hyperactive - recognised change in conciousness
Onset of 1-2 days.
CHANGE FROM BASELINE
Causes of delirum
Infection Intoxication Substance withdrawal Constipation Uncontrolled pain Hypoxia Electrolyte imbalance Urinary retention
What is dementia?
Progressive decline in cognitive function usually occuring 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, recognitiion, ability to self care, and reasoning
What are the most common types of dementia?
Alzheimers Vascular Lewy Body Parkinson's disease with dementia Frontotemporal dementia Mixed (Alzheimers and Vascular type)
How can Alzheimer’s be managed pharmacologically?
Cholinesterase inhibitors such as Donepezil
Antispychotic medications such as memantine or risperidone
Benzodiazapines such as lorazepam
Management of vascular dementia
Optimisation of vascular risk factors (stroke/tia)
What is the difference between Lewy Body dementia and Parkinson’s disease with dementia?
In Parkinson’s disease typical features of Parkinson’s will present and precede confusion by over a year
Lewy Body dementia Parkinsonism tends to be less severe
Both are progressive with prominent auditory or visual hallucinations, delusions are well formed and persistent
What are the main types of incontinence?
Stress
Urge
Overflow
Functional (cognitive impairment, behavioural problems)
What is required for a full continence examination?
Review of bladder and bowel diary
Abdominal examination
Urine dipstick and MSU
PR examination (including prostate in men)
External genitallia review (atrophic vaginitis in women)
A post micturation bladder scan
What is the firstline management for urinary incotincence?
Switching to decafinated drinks Good bowel habit Improving oral intake Regular toileting Pelvic floor exercises Bladder retraining
Why are pharmacological measures for urinary incontinence often contraindicated in older patients?
Antichollenergics adversely affect their cognition
Many of the drugs used for bladder stabalization can also cause postural hypotension leading to increased falls
When might you be suspicious of feacal impaction in a patient who is opening their bowels?
Small amount of type 1 stool
Copious amount of type 6/7 stool
No sensation of defecation
This could be overflow constipation
What type of faecal loading are enemas more effective for?
Soft stool loading
What is the risk with manual stool evactuation?
Bowel perforation
Must be reserved for difficult cases where the risk is outweighed by the positive impact on patient symptoms and wellbeing
When should stimulants laxatives such as senna or laxido be used?
Soft stool constipation
What is are the life-threatening risks of chronic constipation?
Stercoral perforation and ischemic bowel
Pharmacological mangement of hard stool impaction?
Stool softeners such as Docusate sodium (Colace)
What are the 4 types of laxative and what are examples of them?
Osmotic (lactulose, movivcol (macragol))
Stimulant (senna, biasacodyl)
Bulk forming (methylcellulose: fybogel)
Stool softeners (docusate sodium, glycerin suppository)
What are common causes of constipation?
Urinary retention Dehydration Lack of dietary fibre Inactivity/immobility Medication e.g. opioids Stress
What questions should be asked when taking a falls history?
- What were they doing when they fell
- How did the fall happen
- How did they feel before the fall
- Was there any dizziness or lightheadness
- LOC?
- Cardiac symptoms? Palpitations?
- Any weakness
- Any history of falls or near misses
- Normal mobility, any aids?
- Medication history: sedatives, cardiac medications, anticholinergics, hypoglycaemics, opiates
- Head injury?
- Seizure activity
- Associated neurological symptoms
What treatment should be commenced if a large bone is fractured with minimal trauma in a patient over 75?
Osteoperosis treatment
What causes elderly patients to fall?
Delirium Vision loss Hypotension Balance problems Muscle weakness Poor fitting footwear Unsuitable home environment (too dim, insecure rugs or carpets, wet floors) Urinary/feacal urgency Pain TIA
What is syncope?
Temporary loss of conciousness due to diruption of blood flow to the brain
Also known as vasovagal/faint
What is the pathophysiology behind a vasovagal episode?
Vagus nerve receives strong stimulus
Stimulation of parasympathetic nervous system
Parasympathetic activation counteracts the sympathetic nervous system
Blood vessels delivering blood to the brain relax
Blood pressure in cerebral circulation drops
Hypoperfusion of the brain tissue
What are primary causes of syncope?
Dehydration
Missed meals
Extended standing in a warm environment
Vasovagal response to a stimulie such as pain/suprise/blood
What are some secondary causes of syncope?
Hypoglycemia Dehydration Anaemia INfection Anaphylaxis Arrhythmias Valvular heart diease Hypertrophic obstructive cardiomyopathy
Syncope vs Seizure?
Syncope:
Prolonged upright position before the event
Lightheaded before the event
Sweating before the event
Burning/clouding vision before the event
Reduced tone during the episode
Return of conciousness shortly after falling
Seizure Aura (smells, tastes, deja vu) Head turning Abnomral limb positions Tonic clonic activity Tongue biting Cyanosis More than 5 mins Prolonged post-ictal period
Investigations following a fall?
ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome
24 hour ECG if paroxysmal arrhythmias are suspected
Echocardiogram if structural heart disease is suspected
Bloods, including a full blood count (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)
What patients are at risk of falls?
Lower limb muscle weakness Vision problems Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson's disease etc) Polypharmacy (4+ medications) Incontinence >65 Have a fear of falling Depression Postural hypotension Arthritis in lower limbs Psychoactive drugs Cognitive impairment
What common medications can cause falls secondary to postural hypotension?
Nitrates Diuretics Anticholinergic medications Anti depressants B blockers L dopa ACEi
What common medications are associated with falls, not related to postural hypotension?
Benzodiazepines Antipsychotics Opiates Anticonvulsants Codeine Digoxin Sedative agents
What is an important assessment to perform on an elderly patinet presenting with a pressure ulcer?
Nutritional assessment
Which type of dementia presents with fluctuating cognition in comparison to other types?
Lewy Body
How does frontolobal dementia usually present?
Social dishinibition
Family history
What blood tests form part of the ‘confusion screen’
TSH
B12
Folate
Glucose
What type of drug is memantine?
NMDA receptor antagonist
What is Picks disease?
Frontotemporal dementia
In which patients should haloperidol be avoided and lorezapam instead be considered
Patients with Parkinsons disease
What does the STOPP tool indentify?
Where the risk of a medication outweighs the theraputic benifit in certain conditions
Why should TCAs be used with caution in the elderly?
Risk of increased cognative impairement
What questionaire should be used to assess frailty?
PRISMA-7
What are the grades of WHO performance status (0-5)
0 Fully active without restriction
1 Restricted in physically strenuous acitivty but ambulatory and able to carry out light work
2 Ambulatory and capable of all self care but unable to carry out any work activity, up and about more than 50% of working areas?
3 Capable of only limited self care, confined to bed or chair more than 50% or waking hours
4 COmpletely disabled, cannot self-care, totally confinded to chair or bed
5 Dead
What kind of investigation results indicate rhabdomyalysis?
CK
Raised LDH (muscle damage)
Hyperkalemia (liverated from damaged muscle)
Hyperphosphatemia (liberated from damaged muscle)
Hyperuricaemia (liberated from damaged muscle)
Hypocalcemia (calcium is taken into damaged muscle)
In which patients is haloperidol contraindicated in?
Patient’s with Parkinson’s disease, it promotes dopamine blockade so it can result in psychosis and a deterioration in motor function
Use lorazepam instead
Lewy body dementia is the presence of dementia alongside two of the three of which core features?
Fluctuating attention and concentration
Recurrent well-formed visual hallucination
Spontaneous Parkinsonism
What is Charles Bonnet syndrome?
Associated with visual loss, patients describe smaller versions of real life objects commonly or faces or cartoons
They realise these hallucinations aren’t real
It is thought that this is due to damage of visual system itself - not a mental health disorder
Main treatment is reassurance
Common conservative measure for managing postural hypotension?
Standing slowly, dorsiflexing the feet and crossing the legs on standing upright
This prevents diuresis and fluid shifts that can cause a sudden drop in blood pressure
In what patients must tramadol be avoided?
Epileptic patients, as it lowers seizure threshold
What is DOLS (deprivation of liberty safeguard)
A means to protect the rights of patients who lack capacity and are detained in a hospital or care home
What is pseudo-dementia?
Depressive dementia
Severe depression leading to psychomotor slowing, memory impairment and difficulties in concentration
Often presents with significant self neglect and weight loss as a result
