Older persons medicine Flashcards
Osteoporosis
Presence of bone mineral density of less than 2.5 standard deviations below the young adult mean density
Osteoporosis risk factors
Age
Female gender
Corticosteroid use
Smoking
Alcohol
Low BMI
Family history
Medications - SSRIs, antiepileptics, PPIs, glitazones, long term heparin therapy, aromatase inhibitors
FRAX score
Estimates 10-year risk of fragility fracture
Valid for patients aged 40-90
Assesses the following factors - age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, RA, secondary osteoporosis, alcohol intake
DEXA scan if FRAX shows intermediate result
QFracture
Estimates the 10 year risk of fragility fracture
Can be used for patients aged 30-99 years
Larger group of risk factors
Results of FRAX
If FRAX was done without BMD, results are as follows:
- low risk: reassure & lifestyle advice
- intermediate risk: offer BMD test
- high risk: offer bone protection treatment
If FRAX done with BMD, results → reassure, consider treatment or strongly recommended treatment
Assessing patients following a fragility fracture
Patients ≥ 75 years of age:
- should be started on oral bisphosphonate without need for DEXA scan
Patients < 75 years of age:
- DEXA scan arranged → enter into FRAX score which will determine risk
DEXA scan results
> -1 = normal
-1 to -2.5 = osteopenia
< -2.5 = osteoporosis
Osteoporosis mx
Vitamin D and calcium supplementation
Alendronate is first line
25% cannot tolerate alendronate (upper GI SEs) → offer risedronate/etidronate
If cannot tolerate bisphosphonates → strontium ranelate & raloxifene
Pressure ulcers
Develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age
Typically happen over bony prominences e.g. sacrum or heel
Pressure ulcers risk factors
Malnourishment
Incontinence - urinary & faecal
Lack of mobility
Pain
Waterlow score
Widely used to screen for patients who are at risk of developing pressure areas
Includes a number of factors - BMI, nutritional status, skin type, mobility & continence
Grading of pressure ulcers
European pressure ulcer advisory panel classification system
Grade 1 - non-blanchable erythema of intact skin
Grade 2 - partial thickness skin loss involving epidermis/dermis/both. Ulcer is superficial & presents clinically as an abrasion or blister
Grade 3 - full thickness skin loss involving damage to/necrosis of subcutaneous tissue that may extended down to (not through) underlying fascia
Grade 4 - extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures with/without full thickness skin loss
Pressure ulcers mx
Moist wound environment encourages ulcer healing → hydrocolloid dressings & hydrogels; use of soap discouraged
Wound swabs not done routinely
Referral to tissue viability nurse
Surgical debridement for selected wounds
Gait and falling
Normal gait involves:
- neurological system: basal ganglia & cortical basal ganglia loop
- MSK system
- effective processing of the senses eg. sight, sound, sensation
Older → more likely to experience medical problems affecting these systems
Falls risk factors
Fallen previously
Lower limb muscle weakness
Vision problems
Balance/gait disturbances
Polypharmacy
Incontinence
Depression
Postural hypotension
Arthritis in lower limbs
Psychoactive drugs
Cognitive impairment
Falls hx
Where, when?
Did anyone else see the fall?
What happened? Any associated features?
Why?
Fallen before?
Systems review?
PMHx
SHx
Medications that cause postural hypotension
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-DOPA
ACE inhibitors
Medications associated with falls due to other mechanisms
Benzodiazepines
Antipsychotics
Opiates
Anticonvulsants
Codeine
Digoxin
Other sedative agents
Falls ix
Bedside - obs, BP, BM, urine dip, ECG
Bloods - FBC, U&Es, LFTs, bone profile
Imaging - XR chest/injured limbs, CT head & cardiac echo
Falls mx
Offer MDT assessment by a qualified clinician to all patients > 65:
- > 2 falls in last 12 months
- fall requires medical treatment
- poor performance/failure to complete ‘turn 180 test’ or ‘timed up and go test’
Urinary incontinence risk factors
Advancing age
Previous pregnancy & childbirth
High BMI
Hysterectomy
Family history
Urinary incontinence classification
Overactive bladder/urge incontinence - due to detrusor overactivity
- urge to urinate is quickly followed by uncontrollable leakage ranging from a few drops to complete bladder emptying
Stress incontinence - leaking small amounts when coughing/laughing
Mixed incontinence - both urge & stress
Overflow incontinence - due to bladder outlet obstruction
- prostate enlargement
Functional incontinence - comorbid physical conditions impair the patient’s ability to get to a bathroom in time
- dementia, sedating meds, injury/illness resulting in decreased ambulation
Urinary incontinence ix
Bladder diaries
Vaginal examination to exclude pelvic organ prolapse
Urine dipstick & culture
Urodynamic studies
Urge incontinence management
Bladder retraining - lasts for a min 6 weeks
Bladder stabilising drugs - antimuscarinics
- oxybutynin (immediate release), tolterodine (IR) or darifenacin (once daily preparation)
- IR oxybutynin - avoid in ‘frail older women’
Mirabegron (B3 agonist) if concern about anticholinergic SEs in frail elderly patients
Stress incontinence management
Pelvic floor muscle training - min. 3 months
Surgical procedures
Duloxetine - women who decline surgical procedures
