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Older persons medicine Flashcards

1
Q

What are the qs involved in taking a falls hx?

A

Before - what were they doing, how did the fall happen, how did they feel before - dizzy and light headed?
During - loss of conc, loss of continence, seizure features
After - weak anywhere, cardiac sx
Other - has this happened before, full DH, how do they normally mobilise, PMH/current med problems

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2
Q

What is involved in a fall assessment?

A
  • Good hx and exam
  • Mobility assessment - PT/OT
  • CVS exam - ECG and lying standing BP
  • Full neuro exam inc CNs
  • MSK exam - any injuries ?, full exposure, gait
  • Medication review
  • Bone health review
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3
Q

What is osteoporosis?

A

Reduced bone density associated w fragility fractures.
T score <-2.5 and severe = T score <-2.5 pluse fracture.

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4
Q

What are the RF of osteoporosis?

A
  • Post menopausal women
  • Long term steroid treatment
  • Cushing’s syndrome, hyperthyroidism, hyperparathyroidism
  • Smoking, alcohol
  • Increasing age
  • Low BMI
  • Past hx fragility fracture
  • FH
  • Diabetes
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5
Q

What are the medications used to treat osteoporosis and what are the risks associated w them?

A
  • Calcium and vit d supplementation if needed
  • Bisphosphonates eg. alendronic acid, given weekly - oesophageal ulcer and GORD (need to stay upright for 30mins after dose), AF and stress fractures
  • Denosumab - inhibits receptors that cause maturation of osteoclasts
  • Raloxifene - exerts protective action that oestrogen does, inhibits osteoclastic action
  • HRT
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6
Q

Where are the ix into osteoporosis?

A
  • DEXA scan
  • XR - heel, wrist, spine, hip if suspect fracture
  • MRI spine for vertebral fracture
  • Exclude met bone disease - bone profile, VitD, TFTs, cortisol, testosterone
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7
Q

Stress incontinence:
- SX
- IX
- Mangement

A

Sx - involuntary leakage on effort or exertion, when sneeze or laugh or cough, due to incompetent sphincter
Ix - exclude pelvic organ prolapse, bladder diary, urinalysis and dip, cystometry (measures pressure of the bladder when voiding), cystogram
Management:
- Conservative - avoid caffeine, fizzy drinks, excess fluid intake, pelvic floor exercises
- Meds - duloxetine if conservative fails and not fit for surgery
- Surgery - incontinence pessaries if prolapse, bulking agents at bladder neck to aid sphincter, mid urethral slings = gold standard, compresses urethra during increased intra abdo pressure

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8
Q

Urge incontinence:
- Sx
- Ix
- Management

A

Sx - involuntary urine leakage immediately preceded by urgency of micturition, detrusor instability or hyperreflexia causes involuntary detrusor contraction
Ix - cytometry - measures the pressure of ur detrusor muscle
Mangement:
- Conservative - avoid caffeine and excess fluid intake, pelvic floor exercises
- Anticholinergic meds - oxybutynin
- Intravesical injection of botox to paralyse detrusor muscle
- Sacral nerve stim

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9
Q

Overflow incontinence:
- Sx
- Mangement

A

Sx - small amounts of urine leak w/o warning, chronic bladder outflow obstruction causes it eg. BPH or prostatic cancer, constipation
Management - treating the obstruction, may need intermittent self catheterisation

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10
Q

Functional incontinence:
- Sx
- Mangement

A

Sx - pt unable to reach the toilet in time = unfamiliar surroundings, alcohol, dementia, sedating meds or poor mobility
Management - stop sedating meds, mobility aids, bladder training, modifying environment

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11
Q

What is involved in a complete continence examination?

A
  • Review of bladder and bowel diary
  • Abdominal examination
  • Urine dip and MSU
  • PR exam and prostate assessment
  • External genitalia review - atrophic vaginitis
  • Post micturition bladder scan
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12
Q

Anti muscarinics:
- Use
- SEs
- Examples

A

Use - overactive bladder and urge incontinence, relaxes the detrusor muscle
SEs - dry mouth, headache, vertigo, constipation
eg. Solifenacin, trospium, tolterodine

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13
Q

Anti cholinergics:
- Use
- SEs
- eg

A

Used for urge incontinence but not preferentially prescribed in older people - falls risk.
SEs - dry mouth, drowsy, dizzy, headache

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14
Q

B3 adrenergic agonist:
- Use
- SEs
- eg

A

Use - overactive bladder and urge incontinence
SEs - N+D, constipation, UTI, increased HR
eg. Mirabegron

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15
Q

A blockers:
- Use
- SEs
- Eg

A

Use - BPH
SEs - reduced ejaculate, dizziness, oedema, UTI, drowsy
eg. Tamsulosin, doxazosin

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16
Q

5a reductase inhib:
- Use
- SEs
- eg

A

Use - BPH, reduce testosterone so reduced growth of prostate
SEs - reduced ejaculate and libido, erectile dysfunc
eg. finasteride

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17
Q

What sort of patients are at risk of faecal incontinence?

A
  • Diarrhoea
  • Pt w anal problems - obstetric injuries, prolapses, colonic resections, perianal itching
  • Pt w urinary incontinence
  • Frail elderly patients
  • Neurological problems and spinal disease
  • Pt w severe cognitive impairment and learning difficulties
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18
Q

What are some treatable causes of faecal incontinence?

A

Always abnormal and almost always curable:
- Diarrhoea causes eg. injection, IBD, IBS - all can be treated
- Colorectal cancer
- Rectal prolapse
- Third degree haemorrhoids
- Acute anal sphincter injury eg. obstetric and other trauma
- Acute disc prolpase/CES

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19
Q

What is the most common cause of faecal incontinence?

A

Faecal impaction with overflow diarrhoea - can assess for stool impacted on a PR exam.

20
Q

What are the basic interventions for a pt w faecal incontinence?

A
  • Increase fibre and fluids to prevent chronic constipation
  • Remove any constipating drugs or add laxatives
  • Nutrition assessment
  • Mobility assessment - can cause constipation and stop pt from getting to the toilet
21
Q

What are some med interventions for faecal incontinence?

A
  • Antidiarrhoeal drugs eg. loperamide hydrochloride but not to those w hard/infreq stools or acute diarrhoea w/o diagnosed cause
22
Q

What are some CF of faecal impaction?

A
  • Not opening bowels
  • Small amount type 1 stool
  • Copious type 6/7 stool w no sensation of defaecation = impaction w overflow
  • Urinary retention - always do PR to see if impaction
  • Palpable faece
  • Abdominal pain, tenderness and distension
23
Q

What is the management of faecal impaction and loading?

A
  • Enemas for rectal loading
  • Stool softeners - docusate sodium
  • Stool stimulants - senna, bisacodyl
  • Manual evacuation if high risk perforation
  • Laxative co prescription
24
Q

How do you treat a pt w chronic diarrhoea?

A
  • Exclude underlying causes - bowel imaging, stool culture, remove causative meds
  • Exclude faecal impaction
  • Regular toileting and med review
  • Low dose loperamide
25
What are the causes of malnutrition?
- Reduced dietary intake - living alone and not able to look after ADLs eg. dementia, depression, stroke, MND - Malabsorption - chronic diarrhoea, colitis, IBD/IBS, infection, pancreatic cancer/pancreatitis, surgery eg. short bowel syndrome, thyroid disease, DM, Coeliac's - Increased losses or alt requirements eg. catabolic state - Energy expenditure
26
What are some of the RF of malnutrition in elderly people?
- Living alone - Institutionalisation/hospitalisation - People w severe learning difficulties or mental health problems - depression - Pt w dementia - Malabsorption, problems w swallowing, reduced appetite - Poor physical function - stroke, MND
27
What is the presentation of malnutrition in elderly people?
- Insidious weight loss, can be masked by oedema - <16 = severe, 16-17 = mod, 17-18.3 = mild - Fatigue - Cold sensitivity - Non dealing wounds and ulcers
28
What screening tools are used to assess a pt nutritional status?
MUST - Malnutrition Universal Screening Tool 1. Measure BMI 2. % unplanned weight loss 3. Establish acute disease effect and score - pt acutely ill and likely to have no nutritional intake >5 days = score 2 4. Add scores together to assess risk of malnutrition 5. Develop care plan
29
What does MUST recommend for a patient who is at high risk of malnutrition?
- Refer to dietician - Set goals to improve and increase overall nutritional intake - Monitor and review care plan weekly in hospital, monthly in community
30
What are the general measures for treating malnutrition in the elderly population?
- Supplementation - calorie drinks or vitamin supplements - Care for those who are unable to shop/prepare meals eg. meals on wheels - OT if difficulty using feeding utensils - Nausea - antiemetics - Treat oral pathology - Dysphagia for SALT, can thicken foods
31
What is the acute management of severely malnourished patients?
- Clinical assessment - dehydrated? infection? anaemia? hypoglycaemia? - Correct shock, dehydration and electrolyte imbalance - Start refeeding slowly - Prevent refeeding syndrome - no more than 50% of energy requirements to start, slowly increase nutrition, cardiac monitoring in case of arrhythmias, IV supplements of K, PO, Ca, Mg - recheck electrolyte levels
32
What are the biochemical features of refeeding syndrome?
- Fluid balance abnorm - Abnorm glucose metabolism - Hypophosphataemia - Hypomagnesaemia - Hypokalaemia - Thiamine def
33
Who is at risk of refeeding syndrome?
- Anorexia - Chronic alcoholism - Cancer - Elderly pt w comorbidities - Uncontrolled DM - Chronic malnutrition eg. malabsorption, >7 days no food
34
How can sertraline contribute to falls?
Associated w upper GI bleeding - can cause anaemia and hypotension due to upper GI bleed and cause a fall.
35
What is the definition of postural hypotension?
Systolic drop of 20 mmHg or diastolic drop of 10mmHg after 3 mins of standing.
36
What are the complications of malnutrition?
- Impaired immune response w increased risk of infection - Reduced muscle strength - Impaired wound healing - Poor cognition and increased dependency - Impaired recovery from illness and surgery - Poor quality of life
37
How should malnutrition be prevented in adults?
- Screen for malnutrition in all hospital inpt on admission and on a weekly basis, on entering a care home, registration w a GP - Oral nutritional supplements prescribed commonly - Give fortified foods to those at risk
38
What are the RFs of pressure ulcers?
- Immbolility ! - Limb paralysis - Lower limb oedema - Med prob - DM, COPD, HF - UTI - DVT - RA
39
What is the European Pressure Ulcer Advisory Panel grading system?
Grade 1 - non blanchable erythema, discoloured skin, war, oedema, induration, intact skin Grade 2 - partial thickness skin loss, superficial ulcer, red skin Grade 3 - full thickness skin loss Grade 4 - extensive destruction, tissue necrosis
40
What is the management of pressure ulcers?
- Repositioning of pt to avoid - Treat conditions that may delay healing - Pressure relieving support surfaces eg. mattress and cushions - Wound dressings - Pain relief, not NSAIDs - Infection control - wound cleansing and debridement, sterile water for wound cleaning, swabbing
41
What are the common sites for pressure ulcers?
Most commonly on bony parts of the body: - Sacrum/buttock ! - Hips - Heels - Ankle - Elbow
42
What are the different types of falls?
- Syncopal eg. postural hypotension, arrythmia, aortic dissection, valvular heart disease, vasovagal syncope - Non syncopal eg. tripping and falling, epilepsy, hypoglycaemia, hyperventilation w hypocapnia, TIA, poly pharmacy - Multifactorial - Simple
43
What factors predispose pt to fall?
- Fraility and increasing age - Postural hypotension and other cardiac problems eg. AF, aortic dissection, MI, valvular heart disease - Polypharmacy and drowsy drugs - Poor dietary intake - Poor vision and dim lighting - Reduced mobility and balance - Tripping on things on the floor, poor footwear, slippery uneven surfaces, lack of stair handrails and bathroom grab bars - Chronic conditions - arthritis, stroke, DM, IPD, incontinence - Reduced muscle strength
44
What are the ix into a fall?
- CT head - BM, urine dip - often have asymptomatic bacteraemia, better to do MSU and urine culture - CXR - Lying standing BP - Bloods - FBC, U&Es, LFTs, TFTs, coag, bone profile - ECG and echo
45
What are the managements for underlying causes of falls?
- Gait - PT - Visual probs - eye test and glasses - Hearing difficulties and ENT - hearing aids and Epley Manoeuvre - STOPSTART after med review - Cognitive impairment - psych referral - Postural hypotension - med review and increase hydration - Continence - rule out infections and referral to continence nurse etc - Good fitting footwear and OT assessment of living situation, take up rugs, turn on lights, reduce tripping hazards
46
What is the treatment of postural hypotension once all other causes ruled out?
Fludracortisone - increases BP. Normally needs to be started in secondary care. eg. for Parkinson's disease when there is a significant drop causing symptoms. Off licence use.
47
What are some fraility assessments?
- Prisma 7 - TUGT - timed up and go test - Walking speed

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