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Clinical Care > Older Persons > Flashcards

Older Persons Flashcards

1
Q

What is GEMS diamond and when to use

A

Geriatric patients
Environmental assessment
Medical assessment
Social assessment

Use for older patients

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2
Q

Older person circulation problems

A

Increased atherosclerosis =decreased cardiac function
Structural breakdown in the arterial wall -longer thicker wider and stuffer so reduced cardiac output
Damage to vascular endothelium because of increased angiotensin II increased inflammatory markers and nitric oxide, means disruption to elastin and increased collagen so arterial thickening

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3
Q

Older person Circulation problems 2

A

Increase systolic bp, decreased diastolic =increasing after load
Postural hypotension- baroreceptors less sensitive to change in blood volume and heart is less response to adrenaline and noradrenaline

Pooling of blood in the veins of legs - varicose veins

Thrombi and emboli form easily due to calcium deposits damaging vessels

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4
Q

Older person heart problems

A

Ventricles work harder and become thicker and less elastic. This thickening and stiffening decreases filling in the ventricle, thus decreasing cardiac output
Stiffening of heart valves =may cause heart murmur
Sa/Av node decreases in amount of pacemaker cells =arrhythmias
Decreased in bundle branch fibres = bundle branch block
Decreased myocardial sensitivity to beta- adrenergic stimulation

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5
Q

Older person respiratory problems

A

Blunted reflexes - coughing
Decreased ability to clear secretions
Increased susceptibility to infection and disease

Decreased sensitivity to chemoreceptors, sluggish response to the stimuli (leads to lower arterial oxygen concentration, so lower SpO2) (brain stem, phrenic nerve and intercostal muscles)

Changes in bone and teeth alter shape harder to ventilate
Cilia lessen

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6
Q

Older person respiratory problems 2

A

Kyphosis and scoliosis reduce functional space for expansion and contraction of thoracic cavity

Muscle weakness affect lung compliance and ability to keep structures open. Cause wheeze, collapsing causes air trap in alveoli

Decrease in elastic tissue in lungs reduces tidal volume, vital capacity. Alveoli reduce in number less gas exchange

Residual volume increased- leaving stagnant alveoli lead to relative hypercarbia and acidosis

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7
Q

Older person overall problem with nervous system

A

Slower reflexes, delayed responses, changes in balance, altered kinaesthetic senses. So increased risk of falls

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8
Q

Older persons problems with brain

A

Reduced brain size and mass - reduced cortex
Reduction in cerebral blood flow and metabolism- due to atherosclerosis
Central conduction decreased
Shrinkage of brain leads to void between brain and skull
Cause stretching of bridging veins that return blood from inside the brain to dura mater lead to tearing and bleeding
Bleeds can empty into void not notice subdural haemtoma

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9
Q

Older persons problem with nerve cells

A

Reduction in neurones
Synapses decrease and neurotransmitter decreases
Catecholamines synthesis reduces, disposal increases
Neurones accumulate deposits
Nerve endings deteriorate - sensation becomes diminished/ misinterpreted
Pain in injured area may not be felt, may be in another area

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10
Q

Older person problem with renal/ gastric systems overall

A

Saliva decreases not able to process complex carbs
Decreases intestinal motility - constipation
Decrease in gastric secretions
Blood flow to mesenteries decreases reduce nutrients absorbed
Increased risk of gallstones

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11
Q

Older persons kidney problems

A

Decrease in volume and weight
Renal flow decreases
Decrease in glomeruli decreased creatinine clearance
Filtration function decreases
Longer half life in certain drugs (digoxin, penicillin)
Increase in blood urea nitrogen
Decrease in protein intake
More susceptible to dehydration and hyponatremia

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12
Q

Older persons bladder problems

A

Urinary incontinence
Capacity decreases, late sensation
Overflow incontinence

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13
Q

Older person liver problems

A

Decrease in weight
Hepatic metabolism diminishes, decrease in blood flow, decrease in metabolic enzymes
Environmental stresses
Certain drugs metabolise slower (diazepam)
Decrease in number and function of B cells (insulin)

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14
Q

Older person msk problems

A

Muscles atrophy
Muscle fibres are fewer and smaller
Motor neurones decline in number
Ligaments and cartilage lose elasticity
Muscle mass decreases snd is replaced by fat
Lose height and structure e.g kyphosis
Generalised loss of bone density- bone reabsorption exceeds new production

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15
Q

Older person immune system problems

A

Depressed immune response
Decreased fever response
Thymus shrinks so T cell activity decrease
Decline in cell mediate immunity
Increased risk of infection and cancers
Potential for reactivation of dormant shingles and tb
Ability to manufacture antibodies diminished

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16
Q

Older person integumentary problems

A

Skin is thinner, drier, less elastic and fragile
Subcutaneous fat is thinner
Elastic and collagen decrease
Skin tears from light contact
Skin healing slower due to diminished capillary blood flow
Bed sores
Sweat production decreases

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17
Q

Older person sensory changes

A

Presbyopia- normal with age
Small pupils and opacity of the eyes lens - lower visual acuity and makes pupils sluggish
Upward gaze may be limited due to degeneration of elevator muscles
Narrowing of visual fields, decrease peripheral vision
Potential for macular degeneration
Hearing loss

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18
Q

ADME - how is absorption affected in the older person

A

Gastric motility, longer and less
Increase gastric ph due to less production of hydrochloric acid in the stomach - delay absorption of of acidic oral drugs
Passage of food from stomach to intestine less efficient
Reduced gi blood flow less absorption
Can increase effect of ulcerogenic effects e.g NSAIDs

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19
Q

ADME - how is distribution affected in the older person

A

Poor circulation
Changes in body composition, plasma protein concentration and blood flow to major organs
Increased body fat and decreased body water, highly lipid soluble drugs have prolonged duration (benzodiazepines)
Less plasma protein could lead to increased incidences of side effects

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20
Q

ADME - how is metabolism affected in older persons

A

Takes longer in liver
Metabolism directly related to blood flow
Size of liver reduces so number of hepatocytes reduced
First pass metabolism reduces with age, end up achieving higher blood vessels
More at risk of hepatitis particularly with nsaids

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21
Q

Adme -how is excretion affected in the older person

A

Renal function varies, excretion varies
Drugs can build up in older patients due to reduced kidney function
If they have a slow time release may result in toxicity, patient have increased sensitivity to some drugs

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22
Q

What is postural hypotension

A

20mmhg drop in systolic and 10mmHG in diastolic
Or
Below 90 with symptoms

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23
Q

Assessment of dehydration

A

Postural hypotension
Decreased skin turgor - collagen reduced so not reliable
Impaired capillary refill time - circulation may be impaired
Dry mouth
Tachycardia in hypovolaemia

Consider when they are getting fluids. Most may not want to be going toilet lots so drink less fluid

24
Q

What is poly pharmacy

A

4 or more medications

25
Q

Mental health in older person

A

Do not be dismissive for comments about dying
Older patients likely to commit suicide and more violently
May be lonely lost loved ones

26
Q

Mental health tools to use

A

PHQ-9

Geriatric depression scale (more than 5)

27
Q

Why might be confused

A

Hypo, stroke, infection, delirium

28
Q

What is delirium

A

A temporary mental state with sudden onset, usually reversible, including symptoms of poor attention ability to concentrate, disorientation, anxiety and some hallucinations

29
Q

Causes of delirium

A 
A- alcohol 
D- drugs 
E - electrolytes 
L- liver failure 
I - infection 
R- retention (urinary/ constipation) 
I - ICP (raised) 
U - urea 
M - metabolic disease
30
Q

Confusion assessment method

A

(CAM)

  1. Acute onset of mental state changes or fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Altered loc
31
Q

Assess for delirium

A

4 AT on MDCalc

32
Q

Older persons and dementia

A

If not diagnosed refer to memory clinic through the GP

Ask how memory has been different

33
Q

Tests for gait and balance

A

Gait speed test - walk 4m takes longer than 5 seconds this can be indicator of frailty do more than once

Timed up and go test - time frame anything less than 10 seconds - normal, 11-20 normal for frail person, over 20 risk of frailty, over 30 risk of falls make referral

Romberg test - loss of motor coordination, stand up close eyes see if stays upright

34
Q

What is frailty

A

Distinct health state related to the ageing process in which multiple body systems lose their in built reserves
Older people with frailty at risk of adverse events from minor events

35
Q

Signs of frailty

A 
Unintentional weight loss 
Reduced muscle strength 
Reduced gait speed 
Self - reported exhaustion 
Low energy expenditure
36
Q

Risk factors for frailty

A 
Age 
Female 
Exercise 
Diet 
Vitamin d 
Obesity
37
Q

Score to do for frailty

A

PRISMA -7 score

38
Q

What is major trauma

A

Serious and often multiple injuries where there is a strong possibility of death or disability

39
Q

What is TARN and what does it say

A

Trauma audit and research network
2017- trauma in the older person study
Most evidence for trauma comes from army and does not look at older people

Fall of less than 2m is most common cause of trauma in elderly
Lack of identification in elderly means injuries often treated in trauma unit
Need more studies on trauma in elderly

40
Q

What is hector and what did it say

A

Heartlands elderly care, trauma and ongoing recovery

Aim to improve outcomes for older people with trauma
Need to know that one size fits all is not right
Need to stop assuming everyone will have same physiological response
Treat a patient with injuries not an injury on a patient

41
Q

Older person msk considerations in trauma

A

Present of osteoporosis and reduced mineral density - more susceptible to fractures
- advancing age, degenerative changes and osteophyte formation can lead to fixed flex ion deformities in the joints especially Cspine

42
Q

Older person resp considerations in trauma

A

Increased chest wall rigidity, loss of muscle mass, reduced alveolar exchange, reduced central response to hypoxia and hypercapnia
Less compliant chest wall
Muscle mass will lead to increased risk of fatigue with lung or chest wall injury (may need supported ventilation)

43
Q

Older person cvs considerations in trauma

A

Normal response to hypotension increase so CO and SVR
Reduction in atrial pacemaker cells can lower resting heart rate and max is reduced to
Aging myocardium is replaced by collagen and fat, stiffer and less ventricular compliance
Presence of atherosclerosis
Older patient will have abnormal parameters

44
Q

Older person cns considerations in trauma

A

Reduction in brain size and mass
Reduction in nerve cells, cerebral blood flow and metabolism
Slower reflexes, delayed responses and changes in balance
Catecholamines synthesis reduces

45
Q

Mediations to consider in trauma with older patients

A

Beta blockers
Calcium channel blockers
NSAIDs
Warfarin

46
Q

How beta blockers may affect trauma

A

Blocks b-adrenoreceptors, leads to blunting of the contractile and inotropic response. With age related desensitisation may conceal an obvious physiological response

47
Q

How calcium channel blockers may affect trauma

A

May prevent peripheral vasoconstriction and accelerate hypovolaemic shock

48
Q

How NSAIDs may affect trauma

A

May contribute to platelet dysfunction and increase bleeding

49
Q

How may warfarin affect trauma

A

Prescribed to patients at risk of clots, will increase risk of haemorrhage

50
Q

Triage considerations for elderly trauma

A

Use silver trauma if they are 65 and over
Physiology - bp less than 110 after accident
Anatomy - injury to 2 or more regions, suspected shaft of femur fracture, open fracture proximal to wrist/ankle
Mechanism - fall downstairs, from rtc - entrapment more than 30 mins, ejection, death in same incident, pedestrian, cyclist

51
Q

What is sepsis

A

Clinical syndrome caused by the body’s immune and coagulation systems being switched on by an infection

52
Q

High risk groups for sepsis

A 
Under 1 and over 75 
Frail 
Patients having: 
Chemo 
Impaired immune function 
On long term steroids 
On immunosuppressant drugs

Recent surgery
Breach of skin integrity
People who misuse drugs iv
People with lines or catheters

53
Q

What score to use for sepsis

A

NEWS2

54
Q

Prehospital sepsis bundle

A 
Oxygen to maintain sats 
Measure lactate if possible 
250ml fluid bolus if normotensive up to 2ml if hypotension 
Consider Ben pen 
Give paracetamol if in pain

Prealert to receiving hospital

55
Q

Maternal sepsis

A

Pregnant, given birth, termination or miscarriage in last 6 weeks

Abdo pain, diarrhoea, vomiting all common signs

Clinical Care (18 decks)

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