Older persons medicine block Flashcards
What is polypharmacy? How does this cause problems?
When 6 or more drugs are prescribed at any one time.
- Drug interactions
- SE
Geriatricians likely to discontinue meds.
What is involved in discharge planning?
- Decide if package of care needed, put together by allocated social worker
- Takes into account family, carers and significant others
- Aim for max QOL and indep living
- Section 5 = pt medically stable for discharge
What is needed for a pt to be discharged?
- TTOs
- Transport
- Therapy assessment - OT/PT
- Restart package of care
- If required - district nurse referral, palliative care
- Transfer back letter for home
Why do discharges fail?
- Health complications
- Communication breakdown between health care professionals and social services
- Lack of funding
- Family decisions
- Prob w package of care
How are the signs and symptoms of acutely unwell older pt different to younger pt?
- Hypothermia rather than raised temp
- Change in consciousness level eg. hypervigilent or w/drawn
What is fraility?
Health state where multiple body systems lose their reserves and so these pt are at the highest risk of adverse health outcomes.
What are some of the qs to ask when taking a hx of a fall?
- What were they doing and how did they feel before?
- How did the fall happen?
- Dizzy? Lightheaded? Loss of consciousness?
- Cardiac sx?
- Are they weak anywhere?
- Has this happened before or has it almost happened?
- Meds
- Normal mobilisation
What drugs can contribute to falls?
- Sedatives
- Cardiac meds
- Anticholinergics
- Hypoglycaemics
- Opiates
What is involved in exam of a pt who has fallen?
- How does pt mobilise, w what, gait
- CVS exam +ECG, lying standing BP
- Neuro exam
- MSK - assess all joints and if any pain, can be easy to miss injuries
What are the indications for osteoporosis treatment to be started after a fall?
- Large bone fracture w minimal trauma
- >75
What is delirium?
Acute confusion and change in consciousness - hyper or hypoalert, sudden onset and fluctuating symptoms. Important to have collateral hx.
What are the causes and risks of delirium?
Trauma Hypoxia Increasing age NOF fracture smoKer/alc wdrawal Drugs Environment Lack of sleep Imbalanced electrolytes Retention Infection Uncontrolled pain Med conditions
What are the risks of delirium?
- Increased mortality
- Prolonged hospital stay
- Higher complication rates
- Institutionalisation
- Increased risk dementia
How is delirium treated?
- Treat underlying cause
- Orient pt to time and place
- Sedation only when pt a risk to themselves or others
What are the different types of delirium?
- Hyperactive - agitated and confused
- Hypoactive - wdrawn and drowsy
- Mixed
What are the different types of dementia? What are the features of each?
- Alzheimer’s - most common, insidious, behavioural probs, clinical hx to dx
- Vascular - imaging suggested, step wise progression, vascular RF
- Dementia w Lewy body - progressive, hallucinations, delusions
- Parkinson’s w dementia - Parkinson’s sx for over a year before dementia
- Frontotemporal dementia - early onset, lang dysfunc and behavioural probs
- Mixed - Alzheimers + vascular
What is the treatment of dementia?
Alzheimer’s - cholinesterase inhib to slow progression.
Vascular dementia - modify RF.
What are the types of incontinence?
- Stress, cough and laugh = small leak
- Urge, freq void and can’t hold
- Overflow, due to retention, obstruction sx in men w large prostate
- Functional, cognitive impairment/behavioural probs
What qs are involved in continence hx?
- How people void
- Freq
- Sx
- Oral intake and types of drink
- Bowels - stool type and freq
- Full drug hx
- Collateral hx if required
What is involved in a continence exam?
- Review of bladder and bowel diary
- Abdo exam
- Urine dip and MSu
- DRE
- Ex genitalia review esp looking for atrophic vaginitis
- Post micturition bladder scan
What is the management of urinary incontinence?
- Decaf drinks
- Good bowel habit
- Improve oral intake
- Pelvic floor exercises and bladder retraining
- Pharmacological - careful because most drugs not good in elderly people eg. anticholinergics cause of falls
What is the reason for faecal incontinence in the elderly?
- Gaping anal sphincter due to haemorrhoids and chronic constipation
- Can’t exert same about intra abdo pressure to force out constipated stool
What features are found on faecal incontinence exam?
- Shouldn’t find faeces in rectum on exam - can be hard stool causing faecal impaction or soft stool that fills rectum
- Reduced anal tone and sensation = spinal cord pathology
What exam must be done if a pt has urinary retention?
PR - assess for impacted rectum and/or large prostate in male - association between full bladder and full rectum.
What are the fatal risks of constipation?
- Ischaemic bowel
- Stercoral perforation - bowel perforation due to pressure necrosis from faecal mass
What is the management of constipation?
- Enemas - for rectal loading
- Stool softeners and stimulants
- Manual evacuation
- In elderly pt any drug that can cause constipation should be co prescribed w laxative
How do you treat chronic diarrhoea?
- Have to exclude all causes - bowel image and stool culture
- Low dose ioperamide
What are TIAs and what is the risk tool associated w it?
Focal neurological deficits due to no blood supply to part of brain lasting <24 hrs.
ABCD2 score - improve prediction of short term risk of stroke after TIA, high risk = TIA clinic.
What is the management and ix of TIAs?
All pt who have suspected TIA = 300mg aspirin daily.
Ix - bloods, carotid Doppler, CT/MRI
Treat - lifestyle mods, HTN control, statins, surgical intervention for carotid artery disease, antiplatelets
What is crescendo TIA?
Two or more TIAs in a week - high risk stroke
What is a stroke?
Sudden onset focal neurological deficit lasting >24hrs or imaging evidence of brain damage due to infarction or haemorrhage.
How are strokes classified?
Infarct or haemorrhage on brain imaging.
Bamford classification - TACS, PACS, POCS, LACS.
What is a TACS?
Total ant circ stroke - middle and ant cerebral arteries affected. Has the worst prognosis. Need:
- Unilateral weakness of face, arm, leg
- Homonymous hemianopia
- Higher cerebral dysfunc
What is PACS?
Partial ant circ stroke, need two of:
- Unilat weakness face, arm, leg
- Homonymous hemianopia
- Higher cerebral dysfunc
What is POCS?
Post circ syndrome - cerebellum and brainstem affects, need one of:
- CN palsy, contralat motor/sensory deficit
- Bilat motor/sensory deficit
- Eye movement disorder
- Cerebellar dysfunc - DANISH
- Isolated homonymous hemianopia
What is DANISH?
Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia
What is homonymous hemianopia?
Problem w the optic tract eg. R optic tract affected, R temporal fibres and L nasal fibres affected = loss of L temporal visual field and R nasal visual field.
What is LACS?
Lacunar stroke - subcortical stroke secondary to small vessel disease. Need one of the following:
- Pure sensory stroke
- Pure motor stroke
- Sensori motor stroke
- Ataxic hemiparesis
What are the emergency treatments of strokes?
- Thrombolysis for cerebral infarct eg. alteplase
- Anticoagulation reversal or neurosurgical intervention - for intracranial bleeds
What is the not emergency treatment of stroke?
- Give pt who had intracerebral haemorrhage ruled out 300mg aspirin for 2 weeks
- Manage RF w lifestyle/med modifications
- Not permitted to drive for a month
What are the surgical treatments of strokes?
- Carotid endarterectomy
- Decompressive hemicrainectomy if deterioration of clinical condition of MCA infarction
What risk score is used to assess if a pt needs anticoag?
CHAD VASC2
How can end of life or the dying phase be recognised?
- Bed bound
- Semi comatose
- Only able to sip fluid
- Can’t take meds orally
What sx can a dying person experience?
- Pain
- N+V
- Dyspnoea
- Agitation and confusion
- Constipation
- Anorexia
- Terminal resp secretions = death rattle
What is involved in a death certification?
- Check pupils fixed and dilated
- No response to pain
- No breath or HS after 1 min auscultation
- Record cause of death, condition leading to cause, additional condition and contributing factors
