Older Persons Health Flashcards
76F - Mrs B
7.5mg Zopiclone repeat presciption review
Attends annual NHS health check
PMH = hypertension - well controlled by ACEi; osteoarthritis - paracetamol on bad days
What would you ask her next?
What does a typical day look like to you?
Mrs B - Typical day
Wake up at 9am - porridge and banana
Gentle housework until lunch - made from local corner shop groceries
Eats low-quality, high sugar diet -cake, sandwiches, noodles
Would eat healthier - does not enjoy cooking and eating alone
Nearest supermarket too far for her arthritis
Dinner = similar to lunch
4-5 cups of tea a day
Whiskey on special occasions
Good relationship with son - speak on the phone to him (he’s in Manchester)
Sees no one else other than shopkeeper each week
More isolated since husband died
Arthritis makes journeys difficult, no car
Watches soaps and TV dramas for entertainment
Goes to bed at 11pm - takes zopiclone to ‘help her sleep’ - dependent on these
What are the key social determinants and lifestyle behaviours identified in this case that would be important in taking a holistic approach to this Mrs B’s health?
Exercise - difficulty with arthritis
Sleep - difficulty getting to sleep without zopiclone = dependency
Diet - v. poor, increasing CVD risks, diabetes
High caffeine intake
Why does food intake decrease as we get older?
Physiological changes:
Dereased basal mmetabolic rate
Lean body mass
Reduced sensation of taste an smell = less tasty food = less interest
What is malnutrition?
What is undernutrition VS overnutrition?
Malnutrition = diet with incorrect amount of nutrients
Malnutrition can be undernutrition (not getting enough nutrients) or overnutrition (getting too many nutrients - often leads to obesity)
Is malnutrition a normal part of ageing?
No
Although - 10% of over 65s are malnourished
What causes malnutrition?
Age related physical changes = difficult to obtain adequate nutrition
Poor dentition - dental disease, ill fitting dentures, gum disease = painful to eat
Swallowing difficulty - neurological conditions e.g. stroke
Arthritis and declining co-ordination = struggle feeding themselves
Deteriorating eyesight
Cognitive changes and poor mental health - low mood and cognitive decline = do not want to cook, do not know what to buy
Medical conditions = cancers, heart failure, kidney disease, hypothyroidism = impair appetite
Malabsorption syndromes - coeliac disease, IBS
Medications = impair appetite e.g. hypertensives
Reduced activity = weight gain
Dependency on staff / carers
What are the effects of malnutrition on health?
Impaired immune function Poor wound healing Osteoporosis Cognitive impairment Mood disturbance Joint and muscle pain
What does lack of calcium and vit D lead to?
What does lack of vit C lead to?
What does lack of vit B12 / folate lead to?
Osteomalacia - vit d / calcium
Poor wound healing - vit c
Anaemia - vit B12 / folate
What does loss of skeletal mass cause?
Sarcopenia - component of frailty syndrome
Increases morbidity and mortality
What should history taking with older persons include?
Patient And with consent - family members / carers Check for changed to weight and BMI Additional symptoms of malnutrition Social history - living situation, care and functional needs Mental health Drug history PMH Fluid and food diary
What should examination of an older person include?
Weight
BMI
Dentition
Other relevant signs - brittle nails, mouth ulcers, psychological disturbance etc.
What do investigations of older persons include?
Guided by history and examination
May include:
Blood tests - electrolytes etc.
What else should be used in a consultation?
MUST - malnutrition screening tool
Objective indication of risk of malnutrition
How can older persons be treated to help malnutrition?
MDT approach
Doctors = review medications, manage medical conditions, play co-ordinating role
Dietitians = formal nutritional assessment, implement recommendations e.g. calorie and nutrient dense supplements, texture modifications, changes to portion sizes etc.
Occupational therapists = practicalities e.g. shopping, cooking, reminding of meal times etc.
Social care = assess and provide increases support e.g. carers, meal deliveries
Speech and language therapists = unsafe swallow corrected
Dentists = address dental pain, provide better fitting dentures
What is OSA?
How does it affect sleep?
Obstructive sleep apnoea - partial or fully blocked airway, often occurs during sleep
Brain gets starved of oxygen, person must wake up to re-invigorate the musculature of the airway
Results from a partial/fully blocked airway
Tonsils too large, jaw set too far back, excess weight
Airway blocked in sleep → brain hypoxia → mini arousal → sharp intake of breath
↑ risk of CVD/stroke/type 2 diabetes/severe depression/severe COVID-19
How patients with OSA present clinically?
Often unaware they are waking up to correct their airways, therefore primarily complain of excessive daytime sleepiness
Partner complains of their snoring - as patient often unaware of this
Loud snoring, pause in breathing, large gasp of air
Excessive daytime sleepiness (EDS)!
Ideally diagnosed with PSD – expensive + resource intensive
Use STOP-Bang questionnaire
What is meant by the term somnolence?
What is meant by fatigue?
Somnolence = strong desire to sleep, can be pathological or not
Fatigue = physical and/or mental exhaustion not alleviated or facilitated by sleep
OSA increases risks of what?
CVD, stroke, T2DM, independent of weight and age
More severe depression
What do the pauses in breathing lead to in the night?
Hypercapnia = increased CO2 in the brain = cellular death
How do OSA patients experience covid-19 symptoms?
5x more severe
How is OSA diagnosed?
Ideally = PSG although expensive and resource intensive
STOP-bang questionnaire = used for differential diagnosis narrowing
Why may the airway be blocked and how can these issues be fixed?
Too large tonsils - may be removed
Wight gain - opt for weight loss
Set back jaw - opt for mandibular advancement
How does weight gain cause OSA?
More adipose tissue around base of tongue and pharynx = airway more likely to collapse when muscles relax during sleep
Risk factors for OSA/ What can increase OSA severity?
- Sleeping on the back
- Anything impacting REM sleep (muscles are paralysed) - Alcohol, some antidepressants
What is the gold standard treatment for OSA?
CPAP - continuous positive airway pressure
Mask worn at night
Keeps airway open - pneumatic splint keeps airway open
V. effective but low compliance = behaviour changes to get them to adhere to this
other treatments:
- Lose weight, quit smoking, reduce alcohol
- Always consider bed partner!
What lifestyle factors can help OSA?
Quit smoking
Lose weight
Reduce alcohol intake
What is insomnia diagnosis clinically?
ICSD-3 (international classification of sleep disorders) diagnostic criteria:
Difficulty initiating or maintaining sleep
Waking up earlier than desired and resistance going to bed
Difficulty sleeping without parent or caregiver
Daytime difficulties because of sleep
Present for 3 months = chronic
1-3months = short-term insomnia
What may cause insomnia?
Continuous elevated stress response across 24hr day - hyper arousal theory of insomnia
Why are psychotropics not recommended for insomnia?
Side effects are worse than insomnia itself
Effects short lived and can lead to dependence
What is the first line treatment for insomnia?
CBT - cognitive behavioural therapy:
other treatments: Sleep hygiene Relaxation training Paradoxical intention Sleep restriction therapy - retraining people with sleep schedule using short term sleep deprivation
What is insomnia a predictor of?
New incidence / developing depression
In an elderly person, what factors could contribute to sleeping difficulty?
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