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
