Older Persons Flashcards
define CGA
the comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail older person ins order to develop a coordinates and integrrated plan for treatment and long term follow up
what are teh mian components of a CGA?
- problem list: current and past
- medication review;
- nutritional status
- mental health: cognition, mood and anxiety, fears
- functional capacity: basic activites of daily livin, gait and balance, activity/exercise status, instrumental activites of daily living
- social circumstances: informal support from family and freinds, social network, eligibility for being offered care resources
- environment: home environment, facilities and safety wihtin the home environment, transport, accessibility to local resources
what is polypharmacy?
polypharmacy is when 6 or more drugs are prescirbed at once (common in older persons)
how can you ensure safe prescribing in odler persons?
- correct agent is prescribed for correct patient with correct diagnosis
- check for allergies
- check for potnetials interactions wit other durgs
- use generic drug names and write in CAPITALS + dont use abbreviations
- ensure dose, frequency and times, and route of administration is clearly indentified
= always ensure to revidew medications on daily basis and stop meds which are not needed
what is the definition of frailty?
clincially recognisable state of increased vulnerability resulting from ageing associated decline in reserve and function across multiple phsyiologic systems such that ability to cope with everyday or acute strressors is comprised
= low grip strenght, low eenrgy, slowed walking speed, low physical activity, and/or unintentional weight loss
what is the clinical frailty scale?
1-9 ranging from very fit to terminally ill
a way to summarize the overall level of fitness or frailty of an older adult after they had been evaluated by an experienced clinician (look up the scale)
what are teh 5 I’s of geriatrics (aka geriatric giants)
Immobility Instability Incontinence Impaired memory Iatrogenesis
what is teh STOPP/START tool for safe prescribing?
Polypharmacy and inappropriate prescribing are well known risk factors for adverse drug reactions
(ADRs), which commonly cause adverse clinical outcomes in older people
STOPP/START tool used to identify potential patient safety incidents for those on multiple medicines or with long term conditions
STOPP - Screening Tool of Older Persons’ Prescriptions
START - Screening Tool to Alert to Right Treatment
name some of the main clinical conditions in older persons (main geriatric syndromes)
- falls
- confusion
- chronic pain
- depression
- incontinence/constipation
- delirium / dementia
- blackout/collapse
0 fatgue - weigh tloss
- frailty
- slow gati
how can falls be categorised?
syncopal and non syncopal
syncopal = blackout therefoe cardiovascualr or neurogenic cause
pre syncope is the feeling of losing consciousness without blacking out
non syncopal - trip/slip so asses gait/footwear and joints
what are some important questions to ask when an odler person has had a fall?
- what were they doing?
- how did the fall happen?
- did they blackout?
- how did they feel before the fall? dizzy/lightheaded/viusual problems
- cardiac symptoms?
- are they weak anywhere?
- has this happened before?
- medications that they’re on?
- how do they normally mobilise?
what examinations should be done after an older person falls?
- ECG
- lying and standing BP
- bloods
- CT head (if GCS 13 and below)
- cardio and neuro exam
- MSK exam to assess joints
- functional assessment of mobility
what is delirium?
delirium is an acute confusional state, with a sudden onset and fluctuating course - develops over 1-2 days and is recognised by chnage in consiousness either hyper (agigated and confused) or hypoalert (withdrawn and drowsy) and inattention
what can delirium be cuased by?
underlying medical problem, substance intoxications, substance withdrawal or a combo of all
commmon in older persons in hospital, frailer patients, have sensory impairment, cognitive impairment, those having surgery, have severe infections
important to exlcude: infection, electrolyte imbalance, hypoxia, drugs including opiates, urinary retention, constipation and uncontrolled pain
iwhat is delirium usually associated with?
- increased mortality
- prolonged hospital admission
- higher complication rates
- institutionalisation
- icnreased risk of developing dementia
how is delirium managed?
managed with supportive care by treating underlyign cause and orientating them to time and palce
pharm treatment only for extreme cases where patient is at signifcant risk to themelves or others
how do you assess mental capacity in a patient?
To have capacity a person must be able to :
- Understand the information relevant to the decision
- To retain that information
- To weigh that information as part of the process of making a decision
- To communicate his/her decision
what is dementia?
dementia is a progressive decline is cognitive function (occuring over months) affecting different areas of function including: retaining new info, managing complex tasks, language and word finding difficulty, behviour, orientation, recognition, ability to selfcare, reasonign
what are the mian types of dementia?
- alzheimers dementia: most common, slow progression, behavioural problmes common, diagnosed on Hx
- vascualr dementia: second most common, diagnosed on Ix, step wise progression
- lewy body dementia: gradually progressive, auditory or visual hallucinations, delusions well formed and persistent, parkinsonism present
- parkinsons disease with dementia: parkinsons ysmptoms precede confusion by over a year
- frontotemporal dementia: early onset, comples behavioural problems, language dysfunction
- mixed dementia: alzheimers and vascualr type
are patients with dementia able to make decisions regarding their care?
yes, patients are still able to if they have to right level of mental capacity
treatment for alzheimers?
cholinesterase inhibitors to slow progression
what are the types of incontinece?
- stress incontinence: small volumes leak during increased intra-abdo pressure
- urge incontinence: frequent voiding, often cannot hold urine, seen in detrusor overactivity and obstruction
- overflow incontinence: urinary retention, obstructive symptoms with enlarged prostates
- functional incontinence: cognitive impairment or behavioural problems
which exmainations/investgations/special tests need to be acquired when doing a complete incontinence examination?
- review of bladder and bowel diary
- abdo exam
- urine dipstick and MSU
- PR exam and prosate assessment in males
- external genitalia reviews (atrophic vaginitis)
- post micturition bladder scan
what are the non pharm methods to treating urinary incontinence
- decaff drinks
- good bowel habit
- improving oral intake
- regular toileting
- pelvic floor exercises
- bladder retraining
what are the pharm treatments for urinary incontinence?
urge or overflow incontinence: alpha blockers e.g. tamsulosin
urge incontinence: anticholinergics e.g. oxybutynin
how does faecal incontienence occur with aging?
- as body ages rectum becomes more vacuous and anal sphincter can gape due to number of factors including heamarrhoids and chronic constipation
- older people cannot exert same amount of intra-abdo pressure and muscle tension to force out constipated stool
what are teh most common cuases for faecal incontinence?
- faecal impaction with overflow diarrhoea (50%)
- neurogenic dysfunction
what investigations/exams need to be done when assessing faecal incontinence?
- PR examination: asses rectum and prostate, assess anal tone and sensation
- visual inspection around the anus
- stool type assess if in the rectum
- check urinary incontinence jsut in case (can be linked)
what type of stool shoudl raise suspicion of faecal impaction with overflow?
smearing
small amount of type 1 stool
copious type 6/7 stool with no sensation of defecating
what are the complications of feacal imapction/constipation?
- stercoral perforation
- ischaemic bowel if chronic
what is the managment of faecal impaction/constipation?
- enemas for rectal loading and stool softeners and stimulants (if stool is hard dont use stimulants and it will need softening first)
- manual evacuation
- in elderly, any drug that cuases constipation shoudl always be co-prescribed with a laxative
what investigations are needed to assess chronic diarrhoea?
- bowel imaging
- stool culture
- causative meds removed
what is the treatment for chronic diarrhoea?
loperamide given (low dose) and then constipating and enemas regimes
what is important when taking into account palliative care for a patient?
- palliative care should be individualised for each patient and concentrate and focus on their needs
- patient needs to be comfortable and have dignity
- patients may state how they wish to be managed and are able to refuse treatment (but not request it)
- request DNAR
- good communication and a palce to go (hopsices/at home/community hospital beds)
when is palliative care done?
when curative care is longer possible and need to switch to more hollistic approach
what is a recognisble state for End of Life or dying phase?
- bed bound
- semi comatose
- only able to take sips of fluid
- unable to take medicine orally
name some symptoms that people facing end of life may have?
- pain
- N&V
- dyspnoea
- agitation
- confusion
- constipation
- anorexia
- terminal secretions
what does teh death certificaion process include (what is done to check a patient is dead)?
- pupils are fixed and dilated
- non response to pain
- no breath sounds or heart sounds after 1 minute auscultation
what are TIAs?
transient ischaemic attacks are focal neurological deficits deu to blockage of blood supply to a part of the brain lasting less than 24 hours (most often much less than that)
what is teh ABCD2 score? how is it calculated?
risk assessment tool to improve the prediction of short term risk of stroke after a transient ischamic attacl (TIA)
it is calculated by summing up points for: BP, age, clinical features, duration of symptoms, diabetes
ACBD2>=4 high risk
what are the investigations for patients who have a TIA?
- blood tests
- carotid doppler
- brain scan (CT or MRI)
what is the treatment for TIA?
lifestyle modifications
treatment of hypercholesterolemia
treatment of HTN
surgical intervention for carotid artery disease
antiplatelets (aspirin 300mg if high risk to have a stroke)
what is a stroke?
sudden onset of a focal neurological deficit lasting more than 24 hours or with imaging evidence of brain damage due to either infarction or haemorrhage
what is the emergency treatment of strokes?
thrombolysis (alteplase and aspirin 300mg for 2 wks) for cerebral infarct/acute ischaemic stroke syndromes
anticoagulation reversal and/or selective neurosurgical intervention for intracranial bleeds
what are teh diffeent types of strokes?
- total anterior circulation strokes (TACS)
- partial anterior circulation stroke (PACS )
- lacunar stroke (LAC)
- posterior ciruclation stroke (POCS)
what is the ‘FAST’ assessment tool and the ROSIER scale
FAST - (face, arms, speech, time) developed to raise awareness to recognised signs of stroke and call for help early
ROSIER - developed to help medical staff distinguish between stroke and stroke mimic
what is teh NIH stroke scale?
clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients
it has 15 items which scores on levels of consciousness, language, neglect, visual field loss, extra-ocular movement, motor strength, ataxia, dysarthria and sensory loss
what are the rules on TIA/strokes and driving?
following a stroke or TIA you are not permitted to drive for one month - after this time you do so as long as there are no permanent neuro sequale
recurrent TIAs = no driving for 3 months
if a patient has stable neuro symptoms from thei stroke/TIA and they hvae a carotid artery stenosis of 50-99% then what treatment is needed?
- need to be assessed and referred fro carotid endarterectomy within 1 week of onset of stroke or TIA symptoms
- undergo surgery within max. 2 weeks of onset of stroke or TIA symptoms
- be assessed on fitness for surgery
what is a major complication with severe middle cerebral artery infarct?
malignant MCA syndrome - need a decompressive hemicraniectomy !!!!
what pathophysiology/conditions can mimic strokes?
- seizures
- space occupying lesions
- hemiplegic migraine
- multiple scelorsis
- sepsis in those with pre existing neuro weakness
why do NG/PEG need to be considered post stroke?
due to swallowing being affected NGs are often inserted post stroke and the decision to proceed with PEG (if unable to ever tolerate oral feeding) if often complex decision involving family and MDT.
what is teh CHA2DS2VASC score? and HAS BLED score?
used to assess the risk of a thromboembolic event (stroke) in a patient with Afib - to see if patient needs to be anticoagulated
HASBLED is used to assess one year risk of major bleeding in patients on anticoagulants
