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Y3 - Medicine Workbook Qs > Older Persons (C26-28) > Flashcards

Older Persons (C26-28) Flashcards

1
Q

26

  • 88 y/o M
  • A/W right NOF#
  • Recovery to mobilise has been slow
  • Has not opened bowels for 4 days - he usually passes a bowel motion daily

What might have led to him developing constipation? (2 marks)

A
  1. Poor mobilisation following fracture & stay in hospital leading to functional constipation: sedentary lifestyle & lack of fibre in the diet and inadequate fluid intake
  2. Medication-induced constipation: due to polypharmacy (eg. opioids, antacids, antidepressants) & pain medications following fracture (eg. codeine, NSAIDs) can cause constipation as a side effect
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2
Q

26

What examination would you undertake? (2 marks)

A

Digital Rectal Exam (PR)
1. Visual inspection around the anus
2. The rectum, prostate, anal tone & sensation assessed
3. Stool type assessed if in the rectum (impacted)

Abdominal Exam: Faeces can sometimes be palpated if significantly loaded

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3
Q

26

What common medications might impact adversely on bowel motions? (3 marks)

A

CONSTIPATION
1. Analgesics - eg. opiods & NSAIDs
2. Aluminium-containing antacids - iron/calcium supplements
3. Antidepressants - eg. tricyclic (amitriptyline)

DAIRRHOEA
1. Overuse of laxatives
2. Abx treatment (eg. penicillin): disrupts microbiota of gut, allowing proliferation of C. diff.
3. PPI/other acid-suppressive drugs (eg.H2-receptor antagonists

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4
Q

26

What are the other causes of constipation in an older person? (4 marks)

A
  1. Immobility
  2. Weakness of the abdominal & pelvic floor muscles
  3. Malnutrition (poor fibre intake) & Dehydration
  4. Chronic medical conditions (metabolic - hyper/hypocalcaemia, neurologic - dementia, CVS - stroke)
  5. Chronic medication use
  6. Aging effects on colonic motility
  7. Cancer: colorectal cancer & tumour compression of large intestine
  8. Psychological: anxiety, depression
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5
Q

26

What investigations would you do and why? (3 marks)

A
  1. DRE: to look for impacted stool in rectum (should be empty) & anorectal disease that can cause pelvic floor dysfunction
  2. Abdo Exam
  3. AXR: to identify faecal load, impaction or obstruction
  4. Bladder scan: to check if urinary retention is a cause
  5. U+Es, Mg2+, Ca2+: to see if there is electrolyte imbalance
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6
Q

26

How would you manage this man with severe constipation? Consider the management of both soft stool faecal impaction and hard stool impaction? (2 marks)

A

^ in dietary fibre, adequate fluid intake & exercise is advised!

HARD STOOL IMPACTION
1. Osmotic laxative: high dose oral macrogol/lactulose
2. Stool softener: rectal administration of glycerol OR enema of docusate sodium (stimulant lax too!)
3. Sodium acid phosphate with sodium phosphate/arachis oil retention enema
* give the enema of arachis oil overnight before giving an enema of sodium acid phosphate with sodium phosphate the following day

SOFT STOOL IMPACTION
1. Oral stimulant laxative eg. senna
2. Stool softener: rectal administration of bisacodyl OR enema of docusate sodium (stimulant lax too!)
3. Sodium acid phosphate with sodium phosphate/arachis oil retention enema

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7
Q

26

What patient factors might influence their urinary continence? (3 marks)

A
  1. Increasing age
  2. Previous pregnancies & vaginal deliveries
  3. Post-menopausal
  4. High BMI
  5. Pelvic organ prolapse
  6. Pelvic floor surgery (eg. hysterectomy)
  7. Neurological conditions (MS, diabetic neurpathy)
    8) Cognitive impairment & Dementia
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8
Q

26

What are the common types of urinary incontinence? (3 marks)

A
  1. Urge/OAB
  2. Stress
  3. Mixed (SI + UI)
  4. Overflow
  5. Functional
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9
Q

26

List medications that may cause or contribute to urinary incontinence (2 marks)

A
  1. Diuretics: ^ urinary frequency
  2. ACEi: cause cough & worsen SI
  3. Antidepressants & HRT: cause detrusor overactivity
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10
Q

26

List causes of urinary retention (2 marks)

A
  1. Obstruction to outflow of urine - prostate enlargement, fibroids, pelvic tumours
  2. Anticholinergic meds
  3. Neurological conditions (MS, diabetic neuropathy, spinal cord injury)

Lead to urinary retention & overflow incontinence

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11
Q

26

What non pharmacological interventions can be advised to improve urinary incontinence? (2 marks)

A
  1. Bladder retraining (UI/OAB)
  2. Pelvic floor training/exercises (SI)
  3. Lifestyle modifications:
    * weightloss
    * avoid caffeine, alcohol, diuretics
    * avoid excessive/restricted fluid intake
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12
Q

26

List common drugs used to treat an overactive bladder? (3 marks)

A

Antimuscarinics/anti-cholinergics (DOT)
1. Darifenacin
2. Oxybutinin
3. Tolterodine

Beta-3 agonist
1. Mirabegron

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13
Q

27

  • 88 y/o F
  • A/W choking on her food
  • Resident in nursing home after having ^ care needs at home due to ^ cognitive impairment

How would you establish her baseline and trajectory in function over the last 12 months? (3 marks)

A

The Barthel Index for ADL
* Measures a Pt’s ability to complete activities of daily living
* Baseline scores recorded & can see trajectory in function
* But measures v basic function of daily life so pt’s can score well but still be dependent on others for daily life (eg. cooking, laudry)

Nottingham Extended ADL Scale
* Asks about components of function which enable social participation

The Timed Up & Go Test (TUGT)
* Combines assessment of physical ability (able
to ‘get up and go’) & cognition (ability to follow instructions & carrying them out)

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14
Q

27

What are the likely causes of poor oral intake in this patient? (2 marks)

A
  1. Difficulty chewing & swallowing
  2. Constipated
  3. Drug side effects
  4. Anorexia from dementia
  5. Not physically active
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15
Q

27

What are the key priorities in managing this patient? (3 marks)

A
  1. Referral to SALT team for safe fluid & food types/consistencies
    ?????
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16
Q

27

What types of fluid and food consistencies can be recommended by the SALT team? (2 marks)

A

FLUIDS
* Thickened fluids to syrup, custard or pudding consistency

FOODS
* Blended diet: B = thin blended like soup, C = thick blended - can be moulded/holds own shape
* Mashed diet: D = still has some lumps in as not pureed/sieved
* Soft diet: just avoiding high risk foods for aspiration
* Normal diet

17
Q

27

Are there alternative feeding methods available & what is the evidence on the use of enteral (NG/PEG - tube) feeding in patients with dementia? (3 marks)

A

If there are treatable reasons for the person’s loss of appetite (such as indigestion, constipation or a sore mouth) these should be addressed. If the person has swallowing difficulties it may be possible to make food and drink safer for them by changing its texture (such as using softer foods or having thicker drinks).
Even if the person doesn’t want to eat or drink very much or is not able to do so, they can be offered food and drink they like so they can enjoy the taste. Moistening the person’s lips and (if they are able to swallow) offering sips of water or fruit juice can help keep their lips and mouth feeling comfortable

  • Should not use NG/PEG in dementia Pts
  • Doesn’t improve nutrition or survival
  • ^er risk of aspiration pneumonia with NG compared to normal eating & drinking
  • Unpleasant procedure & Pt may try to pull it out
18
Q

27

What does the term “Feed at risk”mean? What information would be important to give with the family/next of kin when discussing this? (3 marks)

A
19
Q

27

What is mental capacity, why is it important to assess for cases like this and how is this determined? (3 marks)

A

The ability to:
* understand info. regarding their care
* retain info.
* weigh up that info.
* explain info. back
* communicate their informed decision

Assessment:
* Time & decision specific (can have capacity for some decisions & not others) > ALWAYS REASSES
* Step 1: Does Pt have an impairment of mind/brain (eg. alcohol or drug use, stroke, dementia, severe LD)
* Step 2: Does the impairment mean Pt unable to make a specific decision when they need to?

20
Q

27

What is a best interest decision? When is this made? (3 marks)

A
  • A decision made for a Pt who no longer has capacity to make their own decision
  • The decision is made with Pt’s best interest in mind, with knoweldge of their past & present wishes & values if possible
  • The decision is made with: anyone looking after Pt, next of kin, neighbours
21
Q

27

What is an advance care plan? Who completes this and what is taken in consideration when completing this? (3 marks)

A
  • Pt has convo. with their family/carers/GP (whilst still having capacity) & makes plans & decisions based on their wishes/priorities for future care/treatment (eg. how they want to die)
  • Pt can complete ACP in anticipation of losing capacity in the future
  • ACP is not legally binding > ADTR (advance decision to refuse treatment)/living will is legally binding
22
Q

27

What is a RESPECT form and what do you understand about the discussions that should be held about this? (3 marks)

A
  • Personalised recommendations for a Pts care & treatment in a future emergency in which they are unable to make/express choices
  • Discussed with Pt or next of kin (NOK) - if no NOK apply for IMCA (Independant Mental Capacity Act) where someone appointed to make decision for Pt in best interest
  • Can be reviewed & is not legally binding unless ADRT is signed

Discussions about:
* What is most important to Pt
* Whether Pt wants to refuse any medical care
* How Pt wants to die
* DNR status

Y3 - Medicine Workbook Qs (2 decks)

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