Older Persons Flashcards
Define a Comprehensive Geriatric Assessment (CGA)
- The CGA is holistic and multidisciplinary approach to determine the capabilities of a frail older person (functional, psychological and medical)
- Enables team to be able to develop a coordinated plan for treatment and follow up
- Emphasises quality of life and functional capacity, as well as prognosis and outcomes
List the components of a Comprehensive Geriatric Assessment (CGA)
- Medical problems
- Medications
- Current functional capacity
- Nutritional status
- Social situation e.g. care agreements, family
- Living environment e.g. home, facilities, travel
Describe what frailty means
- Frailty is a distinctive health state whereby many body systems lose their inbuilt reserves
- At increased risk of adverse health outcomes
- Affects which treatments are likely to benefit the individual
Outline the rough categories for the frailty score
- Very fit - very active, fittest for age
. - Well - no active disease and active
- Managing well - well-controlled diseases and mostly active
. - Vulnerable - symptoms can affect function
. - Mildly frail - require help with hard ADL e.g. food shopping
- Moderately frail - require help with all ADL and personal care
- Severely frail - completely dependent (6 month expectancy)
- Very severely frail - completely dependent (end of life)
. - Terminally ill - completely dependent but not frail (end of life)
Describe the concept of polypharmacy
Polypharmacy:
- Generally when > 6 drugs are prescribed at any one time
- But now relates to prescribing or taking more medicines that are clinically required
Describe safe prescribing STOP/START tool and what it aims to do
Generally used for patients > 65 yrs
- A structured, critical examination of a patient’s
medicines list
Aim:
- Reach an agreement with the patient
- Optimise impact of medications
- Reduce ADRs
- Reduce waste
Series of ‘STOPP’ medications to consider stopping, and ‘START’ medications to consider starting
List the causes of syncope in elderly
- Neurally-mediated
e.g.
vasovagal
carotid sinus hypersensitivity - Orthostatic / low blood pressure on standing
e.g.
drugs
hypovolaemia
autonomic failure (diabetics) (orthostatic) - Arrhythmias
e.g.
AF
VT
Torsades de pointes
AV block - Cardiac disease
e.g.
aortic stenosis
ventricular failure
hypertrophic cardiomyopathy - Cerebrovascular
e.g.
vascular steal
Constipation - state the following:
- Definition/pathophysiology
- Presentation
- Investigations
- Management
Definition/pathophysiology:
- Generally described as infrequent bowel motions with the feeling of incomplete evacuation or straining
Presentation:
- Straining on defecation
- Feeling of incomplete evacuation
- Abdominal distention
- Abdominal pain
- Feeling of fullness / loss of appetite
Investigations:
- Firstly, DRE
- Abdominal x-ray if suspect proximal impaction
- Review current medications
- Consider invasive
Management:
- Treat underlying cause
- Consider lifestyle changes e.g. increase mobility, increase fibre
- Consider use of laxatives (osmotic, bulk-forming, stimulant or stool softeners)
Urinary incontinence - state the following:
- Definition/pathophysiology
- Type of urinary incontinence
- Investigations
- Management
Definition/pathophysiology:
- Involuntary leakage of urine
- More common in females
- Cause is often multifactorial
Types:
- Stress
- Urge
- Mixed
- Overflow
- OAB syndrome
Investigations:
- FBC including U&Es
- Urine dip if ?UTI
- Bladder scan (post-micturition)
- Bladder/bowel diary
- Abdominal examination (palpate bladder)
- External genitalia examination and DRE in males
- Examination of S2, S3, S4 dermatomes for any neurological disease
-Invasive urodynamics
- Pad tests
- Cystoscopy
Management:
- Simple interventions e.g. decaffeinated drinks, weight loss, timed voiding
- More complex e.g. bladder retraining and pelvic floor exercises
- Medications: Duloxetine, Anticholinergics, Mirabegron, Botulism toxin
- Topical oestrogen creams (female)
- Surgery
State investigations and appropriate examinations for a patient presenting with a fall history
Investigations:
- Routine bloods including FBC, CRP, U&Es, LFTs
- Blood glucose monitoring
- ECG
- Lying / standing BP
- CT or MRI if suspect head injury
- Consider urine dip if suspect UTI
Examinations:
- Cardiac
- Neurological (CNS, peripheral nerve exams)
- MSK
- Vision
- Gait assessment
Delirium - state the following:
- Definition
- More common in patients with
- Presentation
- Investigations
- Management
Definition:
- An acute confusional state, with a sudden onset and fluctuating course
- Either hypo or hyper -active
- Causes vary (DELIRIUM mnemonic)
More common in patients:
- Frail
- Sensory impairment
- Cognitive impairment
- Recent surgery
- Hip fractures
- Severe infections
Presentation:
Hypoactive
- Withdrawn
- Drowsy
Hyperactive
- Agitated / aggressive
- Confused
Investigations:
- Collateral history is key to distinguish between delirium and dementia (4AT test is useful)
- May need to investigate for underlying e.g. source of infection, cognitive impairment
Management:
- Generally supportive management, treat the underlying cause
- Orient to time and place
- Pharmacological intervention if patient is at risk of harm to self or others
- Prevention is key
- Takes time to resolve (up to 3 months), some may never return to baseline
Dementia - state the following:
- Definition
- 4 main types (in order of frequency)
- Presentation
- Investigations
- Management
Definition:
- Progressive decline in cognitive functioning, affecting different areas of function
4 main types (in order of frequency):
- Alzheimer’s
- Vascular
- Frontotemporal dementia
- Lewy Body or Parkinson’s with Dementia
Presentation:
Depends on type of dementia
- Cognitive impairment e.g. problem solving
- Memory loss
- Confusion
- Mood changes e.g. agitation
- Difficulties with ADLs
Investigations:
Mainly a clinical diagnosis - MMSE (mini mental state exam)
- May want to rule out other causes e.g. CT/MRI head
Management:
- Alzheimer’s = Cholinesterase inhibitors
- Vascular = modify risk factors
List some benefits of carrying out a CGA (comprehensive geriatric assessment)
- Better patient outcomes
- Better functionality of patient
- Reduced rate of remission
- Better patient satisfaction
- Reduced long term care requirements
- Lower costs
List some things you must do when prescribing drugs
- Check patient identifiers
- Check drug allergies
- Check for drug-drug interactions (OTC and prescribed)
- Use generic drug names
- Ensure dose, frequency, timing and route of drug
- Write start date and end/review dates
- Review medications on a daily basis
Suggest why older people are at greater risk of adverse effects from their medications
- Age related changes alter pharmacokinetics and pharmacodynamics e.g. reduced renal function
- Elderly may not understand instructions or complicated medication regime due to polypharmacy, dementia etc.
- Elderly have more co-morbidities therefore greater potential for drug-drug interactions
- Elderly with co-morbidities not often included in clinical trials data
List the top 3 drugs implicated in adverse drug reactions
- NSAIDs including Aspirin
- Diuretics
- Warfarin
List some medications that commonly cause constipation
Analgesics:
- NSAIDs
- Opioids
Anti-diarrhoeals:
- Loperamide
Antiemetics:
- Ondansetron
Antihypertensives:
- β-blockers
- Calcium channel blockers (especially verapamil)
- Diuretics
Anticholinergics
Anti-Parkinson
Antihistamines
Anticonvulsants:
- Gabapentin
- Phenytoin
- Pregabalin
Explain the differences between delirium and dementia
Delirium:
- Acute onset
- Temporary
- Fluctuating course
- Reversible
- Not in keeping with how the relatives know the patient
- Altered consciousness
Dementia:
- Slow, gradual onset
- Progressive course
- Non-reversible
- Grossly in keeping with how the relatives know the patient
- Consciousness not altered
List common causes of falls
Neuropsychiatric:
- Movement disorder
- Sensory impairment (visual or auditory, peripheral neuropathy)
- Cognitive impairment
Cardiovascular:
- Syncope
- Orthostatic hypotension
MSK:
- Muscle weakness
- Instability or poor mobility
- Foot problems
- Obesity
Medications:
- Substance misuse e.g. alcohol
Environmental hazards
List possible causes of delirium
DELIRIUM mnemonic
Drugs e.g. opioids
Electrolyte imbalance
Liver failure
Infection
Retention (urinary or faecal)
Intracranial
Uraemia
Metabolism
List some things you can do to reduce the risk of delirium
- Regular healthy meals
- Adequate hydration
- Preventing constipation
- Staying mobile
- Ensure sensory awareness i.e. hearing aids or glasses
- Family/friend visits if possible
- Sleep
List some differentials for individuals presenting with Dementia-like symptoms
- Delirium (hypo or hyper -active)
- Stroke
- Depression
- B12 deficiency
- Hypothyroidism
- Hypercalcaemia
- Hydrocephalus
- Korsakoff Syndrome (B1 deficiency)
- Adverse drug effect
What is the minimum drop in systolic blood pressure required to diagnose postural hypotension?
20 mmHg
(or a fall of 10mmHg or more in diastolic pressure)
List some end of life medications that can be given for pain relief
- 1st line: Morphine
- Diamorphine
- Oxycodone
- Alfentanyl (reduced renal function)
List some end of life medications that can be given for breathlessness
- Morphine
- Midazolam
- Therapeutic oxygen
List some end of life medications that can be given for nausea and vomiting
- Haloperidol
- Levomepromazine
- Cyclizine
- Metoclopramide
List some end of life medications that can be given for restlessness and confusion
- Haloperidol (antipsychotic)
- Levomepromazine (antipsychotic)
- Midazolam (benzodiazepine)
Give one end of life medication that can be given for respiratory tract secretions
Hyoscine hydrobromide
