OLDER PERSONS MEDICINE Flashcards
1
Q
What is CGA?
A
Comprehensive geriatric assessment
2
Q
What is CGA used for?
A
multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up
3
Q
What is the emphasis of CGA?
A
quality of life
functional status
prognosis
outcomes
4
Q
Why is CGA important?
A
better outcomes, including reduced readmissions reduced long-term care
greater patient satisfaction
lower costs
5
Q
Who is in a CGA team?
A
geriatrician
nurse specialist
occupational therapist
physiotherapist
pharmacist
others as needed (speech and language therapist, dietician)
6
Q
What are the domains of CGA?
A
Problem list – current and past
Medication review
Nutritional status
Mental health – cognition, mood and anxiety, fears
Functional capacity
Social circumstances
Environment
7
Q
What is considered when assessing functional capacity in CGA?
A
basic activities of daily living
gait and balance,
activity/exercise status
instrumental activities of daily living
8
Q
What is considered when assessing social circumstances in CGA?
A
informal support available from family or friends,
social network such a visitors or daytime activities, eligibility for being
offered care resources
9
Q
What is considered when assessing environment in CGA?
A
home environment, facilities and safety within the home environment, transport facilities ,accessibility to local resources
10
Q
Is faecal incontinence ever normal?
A
No, always abnormal
11
Q
How does a patients rectum change as they age?
A
the rectum can become more vacuous and the anal
sphincter can gape due to a number of factors including haemorrhoids and chronic constipation.
Older people cannot exert the same amount of intra-abdominal pressure and muscle tension to force out constipated stool.
12
Q
Why is diminished anal tone sensation important not to miss?
A
Could indicated spinal cord pathology-needs urgent management
13
Q
What is the most common cause of faecal incontinence in OP?
A
1)Faecal impaction with overflow diarrhoea
2nd- neurogenic
14
Q
What type of stool you be suspicious of overflow with impaction?
A
smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation
15
Q
What are the risks of chronic constipation?
A
stercoral perforation and ischaemic bowel
16
Q
What is the management of chronic constipation?
A
utilising enemas for rectal loading and stool softeners and stimulants.
Stimulants don’t work on hard stool.
Some enemas will not work if the rectum is loaded with hard stool and will merely fall out.
17
Q
Management of diarrhoea in OP?
A
underlying causes must be excluded by bowel imaging and stool culture
potentially causative medications removed then care
can focus on firming the stool.
Faecal impaction must be excluded
18
Q
Pharmacological management of diarrhoea in OP?
A
Low dose loperamide
19
Q
What is delirium?
A
Acute, transient and reversible state of confusion ( global disorder of cognition and consciousness). often due to other cause (infection, drugs, dehydration).
Onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.
20
Q
What 2 states of delirium can you get?
A
HYPOactive
HYPERactive
21
Q
what are clinical features of hypoactive delirium?
A
(often confused with depression)
Lethargy
withdrawn
Inattention
Slowness with everyday tasks
Excessive sleeping
22
Q
what are clinical features of hyperactive delirium?
A
Agitation
Delusions
Hallucinations
Wandering
Aggression
23
Q
Patients CAN fluctuate between hypoactive and hyperactive delirium - TRUE OR FALSE?
A
TRUE
24
Q
Causes of delirium? CHIMPS PHONED
A
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic / renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)
25
Assessing the confused patient:
in medical notes look for relevant past medical history such as...
Previous episodes of confusion
head injury
recent admission
stroke
atherosclerosis
26
Assessing the confused patient:
in medical notes look for current medications....
review drugs that may cause / contribute to confusion
e.g. opiates
anticholinergics
benzodiazepams
steroids
Antihistamines
antipsychotics
antidepressants
parkinson drugs
27
Assessing the confused patient:
in medical notes look for social Hx....
Home situation - carers / live alone
evidence of how coping
excess alcohol
excessive drug use
28
Patient's PC: a fall.
What would you ask in Hx?
WHO saw you fall?
WHEN did you fall?
WHERE did you fall?
WHAT happened before/during/after?
WHY do you think you fell?
HOW many times have you fallen?
Meds taken? How do they mobilise usually?
29
What PMH may be relevant in fall Hx?
CVS - arrhythmia, CVD
Resp - COPD
Neuro - Parkinson's, peripheral neuropathy, stroke, dementia
GU - UTIs, incontinence
GI - Diverticulitis, chronic D-, ALD
MSK - Arthritis, chronic pain, fractures
30
Why review meds in OP who has had a fall?
Polypharmacy is RF for falls. Meds have SE for increasing risk of falls.
31
Name meds that increase risk of falls in OP
BBlockers
DM meds
HTN meds
Benzodiazepines
Abx
32
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
33
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
34
What questions does the Abbreviated Mental Test Score (AMTS) ask?
Ask the patient:
1. “What is your age?”
2. “What is the time to the nearest hour?”
3. Give the patient an address, and ask them to repeat it at the end of the test (e.g. “42 West Street”)
4. “What is the year?”
5. “What is the name of this place?” or “What is your house number?”
6. Can the patient recognise two persons (e.g. doctor, nurse)?
7. “What is your date of birth?” (day and month sufficient)
8. “In what year did World War 1 begin?”
9. “Name the present monarch/prime minister/president”
10. “Count backwards from 20 down to 1”
Each questions answered CORRECTLY. gets 1 point.
SCORE OF 6 or less suggests DEMENTIA ? DELIRIUM - further tests to confirm which
35
What would you look for in clinical examination of someone you are assessing for delirium?
Vital signs (e.g. fever in infection, low SpO2 in pneumonia)
Level of consciousness (e.g. GCS/AVPU)
Evidence of head trauma
Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
Asterixis (e.g. uraemia/encephalopathy)
36
There is a patient with suspected delirium- you are asked to do a confusion screen.
What 3 categories of investigation does this involve?
Bloods
Urinanalysis
Imaging
37
What bloods do you need to request for a confusion screen for your patient? And what looking for?
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g.
hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
38
What urinalysis do you need to do for a confusion screen for your patient? Why is this complicated for older patient?
most elderly patients will have a positive urine dip- not enough to diagnose UTI in elderly as cause of delirium.
Need other evidence:
WCC ++
suprapubic tenderness
dysuria
Offensive urine
+ve urine culture
39
What imaging do you need to do for a confusion screen for your patient? What looking for?
CT head- intracranial pathology (bleeding, ischaemic stroke, abscess)
Chest X-ray - pneumonia, pulmonary oedema
40
What is definitive management of delirium?
treat underlying cause
41
Supportive management of delirium?
- Pt has access to aids e.g. hearing aids/ glasses/ walking stick
- encourage independent activities e.g. washing / eating/ toileting
42
Environmental management of delirium?
- Access to clock and other orientation reminders
-familiar obects - photos/ wear own clothes
- involve family / regular carers
- ensure lighting and temperature optimal
43
Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?
Haloperidol 0.5 mg is the 1st-line sedative (oral preferred or IM if refused to take + immediate threat to others)
Parkinson's disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine
44
What score can we use in a clinical setting to evaluate for frailty?
Rockwood clinical frailty score >65yrs
45
Some steps to prevent delirium?
avoid drugs that cause: opiates / benzodiazepines
asses factors that cause: pain control / drugs
Identify those at risk and monitor
use supportive and environmental management approaches for all patients
46
Bedside investigations for OP that has Hx of fall?
Vital signs - BP, HR, RR, O2 sats, temp
Lying and standing BP (orthostatic hypotension)
Urine dip (blood ++ in rhabdo)
ECG - bradycardia, arrythmia
Cognitive screen
Blood glucose (Hypoglycaemia)
47
Blood investigations to do for OP w/ Hx of fall?
FBC
U+Es - dehydrated, electrolyte abnorm, rhabdo
LFTs - chronic alcohol use
Bone profile - Ca levels in malignancy, over supplementation of Ca
48
Imaging investigations for Op w/ Hx of fall?
CXR
CT head
Echo
49
Use surgical sieve / systems review to AR causes of falls in OP
CVS - arrhythmia, ortho hypoT, Bradycardia, valvular heart disease
Neuro - Stroke, peripheral neuropathy
GU - Incontinence, UTI
Endocrine - Hypoglycaemia
MSK - Arthritis, Disuse atrophy
ENT - BPPV, ear wax
50
How are OP who have fallen assessed?
Falls risk assessment
- ID people over 65 who have had 1+ falls in last 12/12.
- Take full Hx
- note RF
- assess gait and balance - use Timed Up and Go test +/- Turn 180deg test.
See CKS Nice guidance - falls risk assessemnt
51
Commonly offered interventions for OP with recent falls Hx?
Strength and balance training
Home hazard assessment and intervention
Vision assessment
Medication review
52
Define capacity
The ability to 1) understand, 2) retain, 3) weigh up information and 4) communicate a decision
53
When assessing capacity, what assumption should you start with?
Always start with the assumption that the patient DOES have capacity.
54
What steps are taken in assessing capacity?
1. Maximise capacity - i.e. start from the presumption that patient has capacity to make decision. Offer audio/written information. Have family/friends present to help communicate. Discuss options in a way that they remember
Still unsure if pt has capacity? Move to step 2.
2. Assess capacity - can they understand? Retain?
Weigh up info? Communicate decision?
If not - need advanced decisions as pt may lack capacity.
3. Next - Is there an advance decision to refuse treatment (always present in England).? Has someone else been given legal authority to make decision?
If yes, that makes decision. If not, you make decision.
4. Reach agreement with team about treatment and care.
55
Characteristic pathological feature of Lewi-Body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
56
Features of Lewy-Body dementia?
Progressive cognitive impairment
Parkinsonism
Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
57
Difference in features of Alzehimers and Lewy-Body
Lewy body- progressive cognitive impairment
Alzheimers- early impairment in attention/memory and executive function rather than just memory loss and cognition may be fluctuating
58
Diagnosis of Lewy body dementia?
Usually clinical
Increasing use of single-photon emission computed tomography (SPECT)
The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%
59
Management of Lewy body dementia?
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's
60
Drug to avoid in Lewy body dementia and why?
neuroleptics should be avoided in Lewy body dementia-->patients are extremely sensitive and may develop irreversible parkinsonism.
61
Pathophysiology of Alzheimers?
cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
62
Name a NMDA receptor antagonist?
Memantine
63
Memantine indications?
Alzheimers
Lewy body dementia
64
What features make delirium a more likely diagnosis than dementia? (Pass Med)
Fluctuating symptoms e.g. worse at night, then normal
Impairment of consciousness (dementia does not see this until very late on)
Abnormal perception (e.g. illusions and hallucinations)
Agitation, fear
Delusions
65
If of the main factors of delirium is impairment of consciousness, how would you evaluate for this in your in your patient?
Reduced score on the Glasgow coma scale e.g. 12/ 15
often accompanied with psychotic symptoms
66
Why must be very careful in treating an elderly patient for delirium when they have a background of Parkinsons / Lewy Body dementia?
Haloperidol 0.5 mg is the 1st-line sedative
Parkinson's disease- antipsychotics can worsen symptoms
1. Reduce Parkinson meds
2. if urgent treatment - use atypical antipsychotics e..g clozapine
67
What given for patient with delirium when Haloperidol contraindicated? Why would it be?
Low-dose lorazepam if haloperidol is contraindicated (atpical)
for people with Parkinson's disease, Lewy-body dementia, or prolonged QT interval
68
What is delirium?
Acute confusional state, sudden onset and fluctuating state
69
How long does delirium develop over?
1-2 days
70
How can you recognise delirium?
Change in consciousness either hyper or hypo alert and inattention
71
What is delirium an indication of?
Frailty
72
What is delirium associated with?
Increased mortality
prolonged hospital admission,
higher complication rates
institutionalisation and increased risk of developing dementia
73
What is the resolution of delirium like?
It takes a while to resolve and can take up to 3 months to get back to normal level of functioning.
Some people may never return to their baseline
74
How do you recognise the end of life or dying phase?
Patient may be:
Bed bound
Semi-comatose
Only able to take sips of fluid
Unable to take medicine orally
75
What are symptoms patients may have at the end of their life?
Pain
Nausea and vomiting
Dyspnoea
Agitation
Confusion
Constipation
Anorexia
Terminal secretions
76
What do you check for in the death certification process?
Check that the pupils are fixed and dilated
No response to pain
No breath or heart sounds after 1 min of auscultation
77
Who writes the death certificate?
A doctor that has cared for the patient within the last 14 days
78
How does the death certificate outline the cause of death?
1a- Cause of death
1b- Condition leading to cause of death
1c- Additional condition leading to 1b
2- Any contributing factors or conditions
79
What is the process for cremation paperwork?
Completed by 2 independent doctors.
Part 1- completed by doctor who knows the patient.
Part 2- by an independent doctor 2 years post registration, seeking confirmation of the cause of death from a variety of sources.
80
When should a death be reported to the coroner?
When a doctor knows or has reasonable cause to suspect that the death occurred due to:
Poisoning, use of controlled drug, medicinal product or toxic chemical
Trauma, violence or physical injury
Related to any treatment or medical procedure
Self harm
Injury or disease attributed to patients work
notifiable accident, poisoning or disease
neglect
otherwise unnatural
81
Aside from certain causes of death, when should the death be reported to coroner?
Occurred in custody or in state detention
No attending practitioner attended the deceased at any time in the 14 days prior to death or no attending practitioner is available within a reasonable period to prepare an MCCD
Identity of deceased is unknown
82
What is the coroners role?
To determine who died, where they died and how they died.
They do not comment on care but do have powers to insisit on further local investigation.
Coroners can decide to hold an inquest to ascertain the answers to the questions above.
83
What to ask about when taking a continence hx from a patient?
Ask about:
how void
how frequent
What other symptoms -e.g burning?
oral intake
types of drinks consumed
bowel habit (stool type/frequemcy)
Drug Hx
Collateral Hx if needed
84
What are simple non drug management advice for continence
non caffeinated drinks
good bowel habit (water/fibre)
improve oral intake
regualr toileting
pelvic floor exercises
bladder retraining
85
Define urge incontinence
Frequent uncontrollable leaking / emptying after urge. cant hold urine - nocturnal incontinence is common.
see with detrusor overactivity can also get with obstruction
86
Define overflow incontinence
Urinary retention - e.g. obstructive symptoms in man with enlarged prostate
87
What would you do when to examine a patient for continence - examination and investigations
Examination:
Abdominal examination
PR - prostate men
external genitalia - atrophic vaginitis in women
Investigations:
Urine dip stick and MSU
Post micturition bladder scan
Other:
review patients bladder / bowel diary
88
Examining an older woman with stress incontinence - what look for ?
Pelvic floor weakness
Prolapse- e.g uterine
Pelvic masses
Urethrocele
89
What would you do when to examine a patient for continence - examination and investigations
Examination:
Abdominal examination
PR - prostate / faecal impaction
external genitalia - atrophic vaginitis in women
Investigations:
Urine dip stick and MSU
Post micturition bladder scan
Other:
review patients bladder / bowel diary
90
What co-morbidities need to rule out when dealing with a patient with incontinence?
Neurological cause - brain damage can be cause
Parkinsons
MS
Stroke
Dementia
spinal cord lesion // trauma
91
What co-morbidities need to rule out when dealing with a patient with incontinence?
Neurological cause - brain damage can be cause of urge incontinence/detrusor overactivity
Parkinsons
MS
Stroke
Dementia
spinal cord lesion / trauma
92
Why are drugs for incontinence problematic in older people?
Antimuscarinics are used - increase anticholingeric burden and cognitive impairment
93
Why are drugs for incontinence e.g. oxybutinin problematic in older people?
Increases the anticholingeric burden - older patients are likely to be taking ++ anitmuscarinic drugs.
This can cause cognitive impairment
Can cause hypotension - risk of falls
94
What are some side effects of antimuscarinic drugs for continence e.g. oxybutynin /
Dry mouth / eyes / skin
Drowsiness
Urinary retention
Constipation
Tacchy
Transient hypotension
glaucoma precipitation
95
What is frailty?
Frailty is a syndrome of age-associated declines in physiologic reserve and function across multiorgan systems. This leads to increased vulnerability for adverse health outcomes
96
Is frailty a disease?
NO- frailty it is the inability to withstand physical / psychological stressors.
can occur on a background of natural ageing or be triggered by disease.
97
What are the common features of frailty (Frailty Phenotype)?
Weakness - measure grip strength
slowness (walking speed)
low level of physical activity
Feeling of exhaustion
unintentional weight loss >5kg in 1 year.
98
What patient groups is it useful to assess for frailty?
Surgical patients
Cardiovascular disease
cancer
HIV
99
What are pts with frailty more at risk of?
Falls
Anxiety
depression
unplanned hospital admissions
100
What are the two models of frailty ?
Frailty Phenotype - features e.g. weight loss, exhaustion etc.
Rockwood - looks at accumulation of deficits (e..g loss of hearing, dementia, tremor) which combine to increase ' frailty index'
101
How do you prevent frailty?
Physical activity (resistance exercise) to counteract loss of skeletal muscle function - sarcopenia.
Diet - enough protein / calories
Vitamin D - ensure not deficient
102
What are the 5 frailty syndromes- raise suspicion that pt has frailty (prev: Geriatric Giants)
Falls
Immobility (e.g. sudden change ‘stuck in toilet’)
Delirium
Incontinence (change / new onset / worsening)
Susceptibility drug side effects (e.g. confusion with codeine, hypotension with antidepressants).
103
After you have recognised a patient with frailty, how should they be managed?
A comprehensive Geriatric Assessment
A holistic review looking at:
Optimising current illnesses
Individual Goal setting
Drug review
Care planning - personalised escalation, end of life care, advanced planning
Multidisciplinary team members:
Geriatrician
Occ therapist / community carer
Mental health / social worker
Specialist nurse
104
What cognitive assessment tool could you use for a pt with suspected dementia ?
NICE -lots
e.g 6-point `Cognitive impairment test (6-CIT)
- temporal orientation
- address recall
- count back from 20
- months of the year in reverse
Score 0-7 out of 28 = normal
8 or more out of 28 = significant
Oxford clinical med book says AMTS and Mental state examination
105
What are some reversible causes of dementia you might find on investigation (bloods)
high TSH - hypothyroidism
Low B12
Low folate
low thiamine (alcohol)
low Ca
106
What bloods would you order for pt with dementia ?
FBC
ESR / CRP
U&E
Ca
HbA1c
LFT
TFT
serum B12/folate
107
What bedside investigations might you do for dementia patient?
urine microscopy and culture (if indicated)
ECG
108
What imaging might you order for dementia pt?
MRI / CT - rule out subdural haematoma / normal pressure hydrocephalus
CXR - infection
EEG - suspect delirium, front temporal dementia, CJD, seizure
109
Define dementia
Dementia is irreversible, progressive decline and impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion).
This occurs without impairment of consciousness.
110
What is the most common type of dementia in UK
Alzheimer’s dementia
111
What histological finding is seen in Alzheimer's?
amyloid plaques (clumps of beta-amyloid) and neurofibrillary tangles ( tau protein).
112
What are the clincial features of Alzeimer's?
Progressive global cognitive loss (can affect all areas of brain)
most common is memory loss. Executive function loss (planning / reasoning)
speech
visuo-spatial skill: orientation.
113
RF for Alzheimers
1st degree relative
Downs syndrome
loneliness (living alone)
low physical activity
smoking
Vascular (high BP, DM, dyslipidaemia, AF)
114
Management of Alzheimers?
Acetylcholinesterase Inhibitors - Rivastigmine
Memantine - NMDA antagonist for severe disease / AChE not tolerated
115
How common is vascular dementia?
2nd most common type
116
What are some RF for vascular dementia
9x risk if had a stroke
hypertension
smoking
diabetes
hyperlipidaemia
obesity
hypercholesterolaemia
117
What happens in vascular dementia and how does it progress?
multiple small cerebrovascular infarcts
stepwise progression - stable period and then acute deterioration
118
What are the clinical features of vascular dementia?
cognitive impairment following event
mood disorders - psychosis, delusions, hallucinations and paranoia
Seizures
Memory disturbance
Gait/speech/emotional disturbance
Attention difficulty
Visual / motor symptoms
119
What do you find histologically in Lewy body dementia?
Spherical Lewy body proteins (alpha-synuclein) are deposited in the brain.
Lewy body proteins deposited mainly in substantia nigra in Parkinson's disease.
120
What are the clinical features of Lewy body dementia
Fluctuating cognitive impairment
detailed visual hallucinations
later Parkinsonism develops
problems with complex tasks and sleep disorders common
121
What happens to brain in fronto-temporal dementia?
Frontal and temporal atrophy with loss of spindle neurons
122
What are the clinical feature of fronto-temporal dementia?
executive impairment
behavioural changes- disinhibition
emotional apathy
inability to recognise faces/objects
speech takes effort / not fluent
123
What are some differencials for dementia?
HIV related dementia
Normal pressure hydrocephalus
Creutzfeldt-Jakob disease
Severe depression
124
What medications can impair cognition and look like dementia
Anticholinergics
sedatives - benzodiazepams
opioids
corticosteroids
125
A frail elderly pt has urge incontinence (overactive bladder). The drug treatment for this is antimuscarinics.
e.g. oxybutynin.
However, we know these are bad in frail, older pts. What drug can we give her instead?
mirabegron !
(a beta-3 agonist) if concern about anticholinergic side-effects in frail elderly patients
