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Y2 - LMAP > Older Persons Health > Flashcards

Older Persons Health Flashcards

1
Q

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?

A

What does a typical day look like to you?

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2
Q

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?

A

Exercise - difficulty with arthritis

Sleep - difficulty getting to sleep without zopiclone = dependency

Diet - v. poor, increasing CVD risks, diabetes

High caffeine intake

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3
Q

Why does food intake decrease as we get older?

A

Physiological changes:
Dereased basal mmetabolic rate
Lean body mass
Reduced sensation of taste an smell = less tasty food = less interest

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4
Q

What is malnutrition?

What is undernutrition VS overnutrition?

A

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)

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5
Q

Is malnutrition a normal part of ageing?

A

No

Although - 10% of over 65s are malnourished

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6
Q

What causes malnutrition?

A

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

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7
Q

What are the effects of malnutrition on health?

A 
Impaired immune function
Poor wound healing
Osteoporosis
Cognitive impairment 
Mood disturbance
Joint and muscle pain
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8
Q

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?

A

Osteomalacia - vit d / calcium

Poor wound healing - vit c

Anaemia - vit B12 / folate

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9
Q

What does loss of skeletal mass cause?

A

Sarcopenia - component of frailty syndrome

Increases morbidity and mortality

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10
Q

What should history taking with older persons include?

A 
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
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11
Q

What should examination of an older person include?

A

Weight
BMI
Dentition
Other relevant signs - brittle nails, mouth ulcers, psychological disturbance etc.

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12
Q

What do investigations of older persons include?

A

Guided by history and examination
May include:
Blood tests - electrolytes etc.

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13
Q

What else should be used in a consultation?

A

MUST - malnutrition screening tool

Objective indication of risk of malnutrition

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14
Q

How can older persons be treated to help malnutrition?

A

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

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15
Q

What is OSA?

How does it affect sleep?

A

Obstructive sleep apnea - 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

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16
Q

How patients with OSA present clinically?

A

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

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17
Q

What is meant by the term somnolence?

What is meant by fatigue?

A

Somnolence = strong desire to sleep, can be pathological or not

Fatigue = physical and/or mental exhaustion not alleviated or facilitated by sleep

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18
Q

OSA increases risks of what?

A

CVD, stroke, T2DM, independent of weight and age

More severe depression

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19
Q

What do the pauses in breathing lead to in the night?

A

Hypercapnia = increased CO2 in the brain = cellular death

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20
Q

How do OSA patients experience covid-19 symptoms?

A

5x more severe

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21
Q

How is OSA diagnosed?

A

Ideally = PSG although expensive and resource intensive

STOP-bang questionnaire = used for differential diagnosis narrowing

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22
Q

Why may the airway be blocked and how can these issues be fixed?

A

Too large tonsils - may be removed
Wight gain - opt for weight loss
Set back jaw - opt for mandibular advancement

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23
Q

How does weight gain cause OSA?

A

More adipose tissue around base of tongue and pharynx = airway more likely to collapse when muscles relax during sleep

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24
Q

What can increase OSA severity?

A

Sleeping on the back
Alcohol
Certain classes of antidepressants
REM sleep

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25
Q

What is the gold standard treatment for OSA?

A

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

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26
Q

What lifestyle factors can help OSA?

A

Quit smoking
Lose weight
Reduce alcohol intake

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27
Q

What is insomnia clinically?

A

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

28
Q

What may cause insomnia?

A

Continuous elevated stress response across 24hr day - hyper arousal theory of insomnia

29
Q

Why are psychotropics not recommended for insomnia?

A

Side effects are worse than insomnia itself

Effects short lived and can lead to dependence

30
Q

What is the first line treatment for insomnia?

A

CBT - cognitive behavioural therapy:

Sleep hygiene
Relaxation training
Paradoxical intention
Sleep restriction therapy - retraining people with sleep schedule using short term sleep deprivation

31
Q

What is insomnia a predictor of?

A

New incidence / developing depression

32
Q

In an elderly person, what factors could contribute to sleeping difficulty?

A

x

33
Q

What are hypnotics and why should they not be used long-term?

A

Benzodiazepines = GABA receptor agonists = anxiolytic, hypnotic and sedative effects

Zopiclone = ‘Z’ drug = removes some of the side effects of benzos

Risk of dependence, tolerance, hangover side effects (unsteady gait, drowsiness, confusion), associated with road traffic accidents

34
Q

Mrs B has been using hypnotic medication long term, why is this an issue particularly in older patients?

A

Unsteady gait = higher fall rates in the elderly = morbidity and mortality

More susceptible to cardiorespiratory depression

Reduced social funcitoning die to effects on memory and gait disturbance

Impaired cognitive dunction - can be wrongly diagnosed as dementia

Mood disturbance = aggravation of depression, emotional blunting or anxiety

35
Q

Why do patients feel drowsy during the day on zopiclone?

A

It can help fall to sleep - but low quality sleep - lack of deep restorative sleep

Therefore, when waking in the morning - feel unrested and groggy

Zopiclone also has sedative effects = daytime drowsiness

36
Q

What are some sleep hygiene suggestions to help sleep?

A

Less stressful evenings
Less caffeine - herbal tea or hot chocolate instead of coffee
Screen time
Exercise during the day = help sleep better at night
Reduce alcohol intake

37
Q

What worries does Mrs B have about stopping taking Zopiclone?

A

Cold turkey
Side effects of stopping - withdrawal symptoms
‘How will I sleep?’

38
Q

How can Mrs B’s worries be tackled?

A

Gradually reduce zopiclone dose whilst implementing lifestyle factors

Until eventually she can sleep without zopiclone

39
Q

What are some stats on loneliness and its prevalnece?

A

7 in 10 have a friend who is lonely
92% find it difficult to tell others they are lonely
1M >65 = lonely
8/10 feel judged negatively for feeling lonely
1/3 believe something is wrong with them
13% feel lonely all the time
1/4 know a parent who feels lonely

40
Q

What is the difference between social isolation and loneliness?

A

Social isolation =

  • Objective measure of the number of contacts that people have
  • About quantity and not quality of relationships

Loneliness =

  • Subjective feeling about the gap between a person’s desired levels of social contact compared to their actual level of social contact
  • Perceived quality of the person’s relationships
41
Q

Why is it important to distinguish between social isolation and loneliness?

A

Quality vs quantity: Possible to have a large social network and still feel lonely so measuring social isolation alone does not account for the quality of relationships or subjective experience of individuals

Meaningful solutions: policy makers and researchers need to ensure that solutions are focused on creating and maintaining meaningful relationships that address both social isolation and loneliness

Measurement tools: the “gold standard” measure of loneliness includes both direct (Community Life Survey single-time measure) and indirect (UCLA 3 item scale) measures

42
Q

What are the direct and indirect effects of social isolation and loneliness on health?

A

Social connection (social isolation and loneliness) has impacts on lifestyle. psychological and medical adherence factors

Social connection can impact lifestyle factors e.g. physical activity, nutrition, sleep, smoking, risk-taking behaviours

Social connection can impact psychological factors e.g. appraisal, stress, depression, resilience, meaning / purpose, hopelessness, safety

Social connection can impact medical adherence and compliance e.g. taking medications, following diet plans, executing lifestyle changes

These impacts on lifestyle, psychological and medical adherence factors can have an effect on biomarkers e.g. inflammation, BP, gene expression, neuroendocrine functioning, adiposity, and more

These can lead to morbidities e.g. CVD, CHD, stroke, diabetes

Morbidities can lead to mortality

43
Q

How does loneliness negatively effect each of the health systems below?

Cardiovascular system

Immune system

Neuroendocrine system

Cognition

Psychological health

A

Cardiovascular system

Immune system

Neuroendocrine system

Cognition

Psychological health

44
Q

What barriers do you think older people face in seeking help for social isolation and loneliness?

A

x

45
Q

What are some examples of wider determinants of health?

A

Nutrition
Social networks
Physical activity
Financial well-being

46
Q

What percentage of patients see their GP for social problems?

A

20% - e.g. education, work, housing, finance

47
Q

What is social prescribing?

A

Way of enabling frontline healthcare professionals to refer people to a range of local, non-clinical services (e.g. community gardening to housing charities)

Way of addressing patient’s needs in a holistic manner - often at a lower cost than prescribing medications

48
Q

How does social prescribing work in practice?

A

GP / frontline worker assesses needs to patient

Refers patient to link worker - a person with a background in health and social care who has received special training in social prescribing

Link worker signposts appropriate support and activities to patients

Patient has multiple meetings with link worker over subsequent months

49
Q

Self care VS social prescribing?

A

Self care = broad term encompassing anything done to support own health and well being e.g. painkillers, mindfullness app

Social prescribing = personalised plan to help needs

50
Q

How does social prescribing help?

A

Increased quality of life and mental health

Reduction in use of NHS services

51
Q

What effects outcomes of social prescribing?

A

How well patients are signposted to the right interventions to help their needs
Compliance
How well the interventions work

52
Q

Why is it difficult to measure outcomes of social prescribing?

A

Due to heterogenous (mixing together unlikely substances - like oil and water) nature of the programmes, service users, and their outcomes

53
Q

What are the physical health benefits from exposure to green space?

A

Decreased risk of pre-term birth and small size gestational age

Decreased risk of T2DM

Decreased risk of cardiovascular mortality and all cause mortality

Reduced incidence of stroke, hypertension, dyslipidaemia, asthma, and coronary heart disease.

54
Q

What are the physiological changes from exposure to green space?

A

Reduced salivary cortisol

Reduced diastolic BP

Reduced HR

Changes in HRV (heart rate variability)

55
Q

What are the mental health benefits from exposure to green space?

A

Reduced feelings of stress

Reduced anxiety and depression

Improved attention and memory

Improved childhood development

56
Q

What are the social benefits from exposure to green space?

A

Improved social cohesion and interaction

Reduced crime

Improved work productivity

Increased job opportunities

57
Q

What are some additional benefits to greenspace exposure?

A

Less suffering from cardiovascular, musculoskeletal, mental health, respiratory, neurological, and digestive diseases

Diabetics show better blood sugar ocntrol
Associated with better cognitive development in children

Decrease in BP / hypertension

Outdoor activity improves physical and mental well being more than indoor activities

Decrease in anxiety, negative thinking and lowers levels of depression and stress

58
Q

Can you think of any population groups who might not be able to access green space?

A

x

59
Q

What is the role of physical activity in Ageing?

A
  1. Anti-inflammatory effects = delivers the greatest health benefit in two main ways - by reducing inflammatory visceral fat and releasing anti-inflammatory myokines during muscle contraction
  2. Effects at the mitochondrial level = increased charge in the mitochondria during sedentary behaviour increases ‘electrochemical charge’ across the mitochondrial membrane. Allows leakage of free radicals into the cell causing damage in the cytoplasm and mitochondria. This damage in the cell results in inflammation, which leads to telomere shortening and over time, cell death creating yet more inflammation. This speeds up the ageing process

Using ATP during muscle contraction reduces the charge in the mitochondria and can reverse the above process, and even lengthen telomeres. Physical activity also increases the number and size of mitochondria

  1. Weight loss = however, remember the benefits of being active and overweight outweigh the benefits of weight loss while being inactive
60
Q

What are the 2 most common chronic diseases?

A

Hypertension

Diabetes

61
Q

Lifestyle changes are suggested for which chronic conditions?

A

Hypertension
Hypercholesterolaemia
Diabetes

All to help prevent deterioration

62
Q

How can meeting physical activity recommendations be achieved realistically in daily lives?

A

30 mins of daily exercise target can be met within a commute

2 days of strength exercises/ week can be met by carrying bags of shopping home

63
Q

How does physical activity help in the management of chronic disease?

A

Exercise = significant reduction in systolic and diastolic BP regardless of weight

Even after cardiac event, or with established cardiac disease, exercise can help prevent subsequent hospitalisations

Aerobic / resistance exercise helps reduce mortality for T1DM and T2DM as it increases insulin sensitivity

64
Q

How does physical activity help so many conditions?

A

It induces adaptations in multiple cells and tissues - changes can be seen in the mitochondria, cardiomyoctes and skeletal muscle myocytes

Effect on endothelia to allow for vasodilation

Effect on anti-oxidant systems and anti-inflammatory effects systemically

65
Q

What would a Lifestyle Medicine Prescription for Mrs B involve?

A

Diet - home deliveries from the supermarket for meals, corner shop for snacks and convo with shopkeeper
Batch cooking

66
Q

What matters to Mrs B?

A

She actively engages with NHS (attends annual appointments)

Cares about her health - took the initiative to make the appointment

Refer to dietician

Last cup of tea before 4pm - switch out tea for hot choc

Sleep - fix sleep schedule esp diverging due to social isolation

Join group activities - helps social isolation and if its cooking/exercise, also helps that

Drinking - lower ability to clear, so maybe lessen drinking habits or if she enjoys it, go to the pub and socialise

Take up a healthy hobby

Go outside in the garden or park

Y2 - LMAP (24 decks)

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