Older Persons Flashcards
Falls
History Taking
Differential Diagnoses
Investigations/Examinations
Management
1.) History Taking - may need a collateral history
- who, what, when, where, how, fall history
- LOC? dizziness or lightheadedness? weakness?
- cardiac sx: chest pain, palpitations
- seizure sx: convulsions, biting tongue, incontinence
- medication: sedatives, antihypertensives/arrhythmics, anticholinergics, hypoglycaemics, opiates
2.) Differential Diagnoses - for syncopal (LOC) falls
- reflex syncope (↓BP): vasovagal, situational (e.g. coughing or straining), carotid sinus massage
- postural hypotension
- cardiac syncope: arrhythmias, aortic stenosis, MI/IHD
- side effect of any medication
3.) Investigations/Examinations
- functional assessment of mobility
- cardio exam (inc ECG), neurological exam, MSK exam
- lying and standing BP (lie for 5mins, stand for 1 min and 3 mins): >20 drop in systolic or <90 systolic
- CT head: if neuro deficit or head injury + GCS <13 OR vomiting OR on anticoagulation
4.) Management
- appropriate management of underlying cause
- assess for osteoporosis risk, treatment if >75 + large bone fracture w/ minimal trauma
Delirium
Definition
Investigations
Management
Complications
1.) Definition - acute onset (1-2 days) of confusional state w/ altered level of consciousness
- hyperactive (more common): agitation, confusion, hallucinations, wandering, aggression
- hypoactive: lethargy, withdrawn, drowsy, inattention
2.) Investigations
- basic obs/EWS, GCS/AVPU
- bloods: FBC, CRP, blood cultures, U+Es, LFTs, TFTs, clotting, bone profile, haematinics, glucose
- urinalysis, CXR, CT Head
- cognition: AMT10 –> CAM/4AT (if AMT <8)
- AMT 10: [age, DOB, place, year], 42 west street, address, time, jobs, WW1, president/PM, count 20->1
3.) Management
- treat the underlying cause
- environment orientation: clocks, familiar objects, control noise, adequate lighting, ambient temperature
- pharmacological (last-line): haloperidol (contra… in Parkinson’s disease) or lorazepam
4.) Complications
- increased mortality, prolonged admission, increased risk of developing dementia
- can take up to 3 months to return to baseline whilst some never get back to their baseline
Causes of Delirium (CHIMPS PHONED)
C
H
I
M
P
S
P
H
O
N
E
D
1.) Constipation - often causes hypoactive delirium
2.) Hypoxia
3.) Infection/Intracranial
- UTI, sepsis, meningitis, pneumonia
- stroke, haemorrhage, epilepsy, abscess
3.) Metabolic Disturbance - dehydration, electrolyte imbalance, normal pressure hydrocephalus
4.) Pain - esp if uncontrolled
5.) Sleeplessness
6.) Prescriptions
- anticholinergics, anti-depressants, anti-histamines
- opiates, beta-blockers, corticosteroids, benzos
- dopamine agonists, lithium, calcineurin inhibitors
7.) Hypothermia/Pyrexia
8.) Organ Dysfunction
- hepatic or renal failure
- endo: hyper/hypothyroidism, Cushing’s, Addison’s
9.) Nutrition - malnutrition
10.) Environmental Changes - disorientation
11.) Drugs
- OTC, illicit drugs, smoking
- withdrawal: alcohol, benzos, cocaine, coffee
4 general features of dementia
Definition
Onset
Investigations x4
Pharmacological Treatment x4
1.) Definition - set of diseases characterised by a progressive decline in higher cortical function
2.) Onset - can be early or late
- early onset is <65, late-onset is 65+
- prion diseases and aggressive brain tumours are the most common cause of rapid-onset dementia in young people
3.) Investigations
- general blood tests, random BM, vit B12/folate
- syphilis testing if risk is identified in the history
- assess frailty using clinical frailty score
4.) Pharmacological Treatment - AChEi or memantine
- AChEi: donepezil, galantamine, rivastigmine
- NMDA antagonist: memantine
Delirium vs Dementia
Onset and Progression
Hallucinations
Speech
Consciousness and GCS
1.) Onset and Progression
- delirium: rapid onset with fluctuating course
- dementia: slow onset and steady decline
2.) Hallucinations - present in delirium, rare in dementia
3.) Speech - can both be slow but delirium can be fast
4.) Consciousness and GCS - reduced in delirium
5 Types of Urinary Incontinence
Stress
Urge
Mixed
Overflow
Continuous
1.) Stress - involuntary leakage of urine due to
- intra-abdominal pressure > urethral pressure
- e.g. coughing, straining, laughing, or lifting
- often due to weakness of pelvic floor muscles so commonly seen in post-partum and post-menopause
2.) Urge - sudden urge to urinate
- overactive bladder (detrusor hyperactivity), causing
↑intravesical pressure –> leakage of urine
- causes: neurogenic (e.g. stroke), infection, cancer, drugs (e.g. AChEi)
3.) Mixed - combination of stress UI and urge UI
4.) Overflow
- complication of chronic urinary retention, where damage to efferent fibres –> loss of bladder sensation.
- causes: BPH (most common), SC injury, congenital
5.) Continuous - constant leakage of urine (always wet)
- due to anatomical abnormality (e.g. ectopic ureter, vesicovaginal fistulae)
- may also be due to severe overflow incontinence.
Management of Urinary Incontinence
Clinical Features
Investigations
Conservative Management
Surgical Management
1.) Clinical Features
- detailed clinical hx to categorise the type
- other sx (dys/haematuria), precipitating factors
- bladder diaries can help work out underlying cause
- QoL questionnaire can help quantify the severity
2.) Investigations
- urinalysis (midstream): infection or haematuria
- post-void bladder scan: overflow UI shows a low post-void residual volume
- PR (BPH), external genitalia (atrophic vaginitis)
- urodynamic assessment if unclear aetiology
- others: abdo exam, cystoscopy, IV urogram, MRI
3.) Conservative Management - first line
- improve oral intake, avoid caffeinated drinks
- regular toileting, good bowel habits
- stress/mixed UI: pelvic flow exercises (>3months), duloxetine (SNRI) for stronger urethral contractions
- urge UI: bladder training (at least 6 weeks), anti-muscarincs oxybutynin (should avoid in elderly)
4.) Surgical Management
- urge: botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty
- stress: tension-free vaginal tape, artificial urinary sphincter, open colposuspension
Faecal Incontinence
Aetiology
Faecal Impaction
Investigations
Management
1.) Aetiology - ageing causes the rectum to become more vacuous and the anal sphincter to gape
- cannot exert same muscle tension to force out stool
- risk factors inc: ↑age, frailty, cognitive impairment, LD
- chronic constipation, diarrhoea, urinary incontinence
- anal problems: perianal pathology, anal surgery, obstetric injury, prolapses, colonic resection
- neuro deficit causing ↓anal tone and ↓anal sensation: SC injury, stroke, MS, tumour, infection, spina bifida
2.) Faecal Impaction - stool stuck in rectum or colon
- soft stool can also fill the rectum causing impaction
- faecal impaction with overflow diarrhoea is the most common cause of faecal incontinence
- full rectum is often associated with a full bladder
3.) Investigations
- PR: assess rectum, prostate, anal tone and sensation, stool type if in the rectum
- assess for urinary retention as often linked
- abdominal exam, can sometimes palpate faeces
4.) Management
- enemas (+stool softeners if hard stool)
- laxatives esp if taking drugs causing constipation
- manual evacuation in difficult cases when the risk of perforation is outweighed by the positive impact on sx
- exclude complications: stercoral perforation, ischaemic bowel in chronically constipated
Transient Ischaemic Attacks (TIAs)
Definition
ABCD2 Score
Investigations
Management
1.) Definition - focal neurological deficits due to reduced blood supply to the brain, lasting <24 hours
2.) ABCD2 Score - risk assessment tool to predict the short-term risk of a stroke after a TIA
- uses age, BP, clinical features, duration, diabetes
- score of 4 and above suggests high risk
- crescendo TIA (2+ in a week) also seen as high risk
- high risk should be seen in TIA clinic or seen by a stroke physician
3.) Investigations
- blood tests, carotid USS, CT head, MRI brain
4.) Management
- PO aspirin (300mg) OD started immediately
- lifestyle modification, control BP and hyperlipidemia
- carotid endarterectomy if carotid stenosis
- cannot drive for 1 month (3 months if recurrent)
Types of Strokes
Ischaemic
Haemorrhagic
Others
1.) Ischaemic (85%)
- TOAST classification used for underlying aetiology:
- 1: large artery atherosclerosis (embolus/thrombosis)
- 2: small-vessel occlusion, 3: cardioembolism
- 4: other aetiology, 5: undetermined aetiology
2.) Haemorrhagic (10%) - intracerebral or subarachnoid
- primary: hypertension, cerebral amyloid angiopathy
- secondary: trauma, anticoagulation-associated
3.) Other (5%)
- dissection: separation of artery walls –> occlusion
- venous sinus thrombosis: vein occlusion causes back pressure and ischaemia due to ↓blood flow
- hypoxic brain injury: e.g post-MI
Stroke
Definition
Assessment Tools
Investigations
Enteral Feeding
Differential Diagnoses
1.) Definition - focal neurological deficit lasting >24hrs or w/ imaging evidence of brain damage
2.) Assessment Tools
- Bamford classification: identify the vascular region
- FAST: quick recognition of stroke in public
- ROSIER scale: distinguish stroke and stroke mimic
- NIHSS: measures stroke severity, 15 different criteria
- CHADS-VASC2: suitability for anticoagulation in AF
- HAS-BLED: risk of bleeding if on anticoagulation
- Barthel index: measures disability/dependence in 10 ADLs, assesses functional status and good to monitor
3.) Investigations
- CT-Head to exclude haemorrhagic stroke: ischaemic area becomes hypodense, bleed glows bright white
- MRI-Brain: ischaemia shows a high signal area
- carotid USS to examine carotid stenosis
4.) Enteral Feeding - NG or PEG
- patients with poor swallowing to ↓risk of aspiration
- aspiration can still occur with enteral feeding
5.) Differential Diagnoses
- seizures, space-occupying lesions, multiple sclerosis
- hemiplegic migraine, sepsis in pre-existing weakness
Bamford Classification for Strokes
Total Anterior Circulation Stroke (TACS)
Partial Anterior Circulation Stroke (PACS)
Posterior Circulation Stroke (POCS)
Lacunar Stroke (LACS)
1.) TACS - all 3 of:
- unilateral weakness +/- sensory deficit of FAL
- homonymous hemianopia w/o macular sparing
- higher cerebral dysfunction: dysphasia, visuospatial disorder
2.) PACS - any 2 of the 3:
- unilateral weakness +/- sensory deficit of FAL
- homonymous hemianopia w/o macular sparing
- higher cerebral dysfunction: dysphasia, visuospatial disorder
3.) POCS - one of the following:
- CN palsy and contralateral motor/sensory deficit
- bilateral motor/sensory deficit
- conjugate eye movement disorder
- cerebellar dysfunction
- homonymous hemianopia w/ macular sparing
4.) LACS - one of the following:
- pure sensory or motor deficit
- sensorimotor deficit
- ataxic hemiparesis
Management of Strokes
General Management of Ischaemic Stroke
Carotid Endarterectomy
General Management of Haemorrhagic Stroke
Decompressive Hemicraniectomy
1.) General Management of Ischaemic Stroke
- thrombolysis with alteplase if < 4.5hrs of onset
- contraindications: bleeding disorders, recent trauma, haemorrhage, surgery, acute cerebrovascular event
- lifestyle modification, control BP and hyperlipidemia
- PO aspirin (300mg) OD for 2wks then lifelong PO clopidogrel 75mg OR( aspirin + MR dipyridamole)
- cannot drive for 1 month
2.) Carotid Endarterectomy - ischaemic stroke or TIA
- patients with stable neurological symptoms
- carotid stenosis >50%(NASCET) or >70% (ECST)
- referred w/in 1wk, treated w/in 2wks of onset of sx
3.) General Management of Haemorrhagic Stroke
- PO aspirin (300mg) (rectal/enterally if dysphagic)
- aspirin until 2wks after the onset of the stroke
- reversal of anticoagulation
4.) Decompressive Hemicraniectomy - haemorrhagic
- in severe MCA infarct showing rapid neurological deterioration to prevent malignant MCA syndrome
- referred w/in 24h, treated w/in 48h of onset of sx
- <60, NIHSS 15+, infarct >50% of MCA (on CT)
Capacity
Assessing Capacity
Making Best Interest Decisions
1.) Assessing Capacity - Mental Capacity Act 2007
- understand information relevant to the decision
- retain that information
- weigh that information into decision-making process
- communicate their decision
2.) Making Best Interest Decisions - if lacks capacity
- care of the patient is the first concern
- use advocates the patient may have identified
- what the patient would have wanted if had capacity
- treat patients as individuals and with dignity
Assessments
Comprehensive Geriatric Assessment
Clinical Frailty Scale
1.) CGA - multidisciplinary diagnostic and treatment process identifying limitations of a frail older person
- components: functional capacity, fall risk, cognition, mood, polypharmacy, social support, financial concerns, goals of care, advanced care preferences
2.) Clinical Frailty Scale - rapid frailty screening tool
- between 1 (very fit) and 9 (terminally ill)
- based on comorbidities and need for help with activities of daily living (ADL)
