Older persons

Question 1

What is a CGA?

Answer 1

Comprehensive geriatric assessment
Multidimensional evaluation of a frail patient to achieve optimal health

Question 2

What is included in a CGA?

Answer 2

Physical assessment
Socioeconomic/environmental assessment
Functional assessment
Motility/balance assessment
Psychological/mental assessment
Medication review

Question 3

Define frailty

Answer 3

Distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves
Phenotype model – describes a group of patient characteristics: unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion & low energy expenditure
-3 or more = have frailty

Question 4

What is the clinical frailty score?

Answer 4

Scoring frailty in people with dementia
Degree of frailty corresponds to the degree of dementia
On a scale from 1-9

Question 5

What is polypharmacy?

Answer 5

Use of 5 or more medications
-increased risk of falls
-reduces concordance
-increased adverse drug reactions

Question 6

What is the START/STOPP criteria?

Answer 6

START – screening tool to alert to right treatment: used to prevent omissions of indicated, appropriate medicines in older patients with specific conditions
STOPP – aims to reduce the incidence of medicines-related adverse events from potentially inappropriate prescribing and polypharmacy

Question 7

Define fall

Answer 7

An event which results in a person coming to rest inadvertently on the ground or floor or other lower level
All falls are accidental and mechanical
Falls are either syncopal or non-syncopal

Question 8

List causes of falls

Answer 8

Intrinsic – vision, cognition, vestibular system, CVS, infections
Extrinsic – medications, walking aids, environment, other people, multitasking

Question 9

List tests to do in a patient presenting with a fall

Answer 9

Bloods – FBC, U&E, LFT, bone, TFT, B12/folate, HbA1C, glucose
ECG
MSU/CSU (don’t dip urine in >65 or catheters)
Postural BP
Height and weight

Question 10

List treatments for falls

Answer 10

Medication reviews
Treat ‘reversible’ causes: infection, electrolyte imbalance
Consider bone health & fracture risk management
MDT review – physiotherapy & occupational therapy

Question 11

Define blackout

Answer 11

Transient loss of consciousness
Differentials: syncope, seizure/epilepsy, hypoglycaemia, drug/alcohol, sleep disorders, medication, undetermined

Question 12

List causes of syncope

Answer 12

Vasovagal – simple faint; common and a result of vagal stimulation (pain, fright, emotion)
Peripheral factors – hypotension (commonest cause of syncope)
Carotid sinus hypersensitivity
Pump problem
Outflow obstruction

Question 13

Describe the management of syncope

Answer 13

Treat any cause found and review/reduce medication
Fludrocortisone/midodrine for OH
Education
Driving – inform patient & document any driving advice given

Question 14

Define delirium

Answer 14

An acute confusional state, with a sudden onset and fluctuating course
Develops over 1-2 days & recognised by a change in consciousness either hyper or hypoalert and inattention

Question 15

List investigations to do for suspected delirium

Answer 15

Bloods – CRP, U&Es
Urine microscopy
PR examination

Question 16

Describe the management of delirium

Answer 16

Supportive care
Treating to underlying cause & orientating them to time and place -> can take time to resolve & some people never get back to their baseline
Pharmacological treatment should be reserved for extreme cases

Question 17

Define dementia

Answer 17

Progressive decline in cognitive functioning usually occurring over several months
Affects many different areas of function eg. retention of new information, managing complex tasks, language & word finding difficulty

Question 18

List different types of dementia

Answer 18

Alzheimer’s dementia – most common, insidious onset with slow progression, diagnosed on clinical history but brain may show disproportionate hippocampal atrophy
Vascular dementia – suggestive imaging, step-wise progression
Dementia with Lewy Body – gradually progressive, auditory/visual hallucinations
Frontotemporal dementia – early onset & have complex behavioural problems, language dysfunction may also occur

Question 19

Describe the management of dementia

Answer 19

Alzheimer’s – cholinesterase inhibitors
Vascular dementia – only the ability to modify risk factors

Question 20

Describe the impact of incontinence in older people

Answer 20

One of the major factors leading older people to fall & require 24 hour care
NOT a natural part of the ageing process
Significant impact on mental health & wellbeing

Question 21

Describe the management of urinary incontinence in older people

Answer 21

First line management – switching to decaffeinated drinks, good bowel habit, improving oral intake, regular toileting, pelvic floor exercises & bladder retraining
Pharmacological management can be trialled -> many drugs used can also cause postural hypotension leading to increased falls

Question 22

Describe the management of constipation in older people

Answer 22

Utilising enemas for rectal loading
Stool softeners and stimulants
Manual evacuation is done in difficult cases
Any prescribed drugs that can cause constipation should be co-prescribed with a laxative