Older Persons Flashcards
What is GEMS diamond and when to use
Geriatric patients
Environmental assessment
Medical assessment
Social assessment
Use for older patients
Older person circulation problems
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
Older person Circulation problems 2
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
Older person heart problems
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
Older person respiratory problems
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
Older person respiratory problems 2
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
Older person overall problem with nervous system
Slower reflexes, delayed responses, changes in balance, altered kinaesthetic senses. So increased risk of falls
Older persons problems with brain
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
Older persons problem with nerve cells
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
Older person problem with renal/ gastric systems overall
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
Older persons kidney problems
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
Older persons bladder problems
Urinary incontinence
Capacity decreases, late sensation
Overflow incontinence
Older person liver problems
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)
Older person msk problems
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
Older person immune system problems
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
Older person integumentary problems
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
Older person sensory changes
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
ADME - how is absorption affected in the older person
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
ADME - how is distribution affected in the older person
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
ADME - how is metabolism affected in older persons
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
Adme -how is excretion affected in the older person
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
What is postural hypotension
20mmhg drop in systolic and 10mmHG in diastolic
Or
Below 90 with symptoms
Assessment of dehydration
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
What is poly pharmacy
4 or more medications
Mental health in older person
Do not be dismissive for comments about dying
Older patients likely to commit suicide and more violently
May be lonely lost loved ones
Mental health tools to use
PHQ-9
Geriatric depression scale (more than 5)
Why might be confused
Hypo, stroke, infection, delirium
What is delirium
A temporary mental state with sudden onset, usually reversible, including symptoms of poor attention ability to concentrate, disorientation, anxiety and some hallucinations
Causes of delirium
A- alcohol D- drugs E - electrolytes L- liver failure I - infection R- retention (urinary/ constipation) I - ICP (raised) U - urea M - metabolic disease
Confusion assessment method
(CAM)
- Acute onset of mental state changes or fluctuating course
- Inattention
- Disorganised thinking
- Altered loc
Assess for delirium
4 AT on MDCalc
Older persons and dementia
If not diagnosed refer to memory clinic through the GP
Ask how memory has been different
Tests for gait and balance
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
What is frailty
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
Signs of frailty
Unintentional weight loss Reduced muscle strength Reduced gait speed Self - reported exhaustion Low energy expenditure
Risk factors for frailty
Age Female Exercise Diet Vitamin d Obesity
Score to do for frailty
PRISMA -7 score
What is major trauma
Serious and often multiple injuries where there is a strong possibility of death or disability
What is TARN and what does it say
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
What is hector and what did it say
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
Older person msk considerations in trauma
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
Older person resp considerations in trauma
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)
Older person cvs considerations in trauma
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
Older person cns considerations in trauma
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
Mediations to consider in trauma with older patients
Beta blockers
Calcium channel blockers
NSAIDs
Warfarin
How beta blockers may affect trauma
Blocks b-adrenoreceptors, leads to blunting of the contractile and inotropic response. With age related desensitisation may conceal an obvious physiological response
How calcium channel blockers may affect trauma
May prevent peripheral vasoconstriction and accelerate hypovolaemic shock
How NSAIDs may affect trauma
May contribute to platelet dysfunction and increase bleeding
How may warfarin affect trauma
Prescribed to patients at risk of clots, will increase risk of haemorrhage
Triage considerations for elderly trauma
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
What is sepsis
Clinical syndrome caused by the body’s immune and coagulation systems being switched on by an infection
High risk groups for sepsis
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
What score to use for sepsis
NEWS2
Prehospital sepsis bundle
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
Maternal sepsis
Pregnant, given birth, termination or miscarriage in last 6 weeks
Abdo pain, diarrhoea, vomiting all common signs
