Older Persons Medicine (geriatrics/palliative care/stroke medicine)

Question 1

What are some causes of constipation in an older patient?

Answer 1

Dehydration
Low-fibre diet
Sedentary lifestyle (post operation)
Diabetes-induced
Polypharamacy
Dementia/parkinson’s
electrolyte imbalances (hypok, hyperca, hypermg)
Link to depression

Question 2

What examination would you undertake in an elderly patient with constipation?

Answer 2

Abdominal exam
DRE

Question 3

What medications can affect the bowels?

Answer 3

Constipation:
Opoids
NSAIDs
Antipsychotics
Antidepressants
Antihistamines
Ca channel blockers

Diarrhoea:
PPIs
Abx (C.diff)

Question 4

What investigations would you do in somebody with constipation?

Answer 4

AXR - rule out faecal impaction
FBC - iron deficiency anaemia (cancer)
TFTs - hypothyroidism
U+Es - electrolyte abnormalities
HbA1c - diabetes
Bladder scan - often urinary retention too
Colonoscopy - if suspect malignancy

Question 5

How do you manage severe constipation?

Answer 5

Soft stool faecal impaction:
1. Enema
2. Stool stimulants (Bisacodyl)

Hard stool faecal impaction:
1. Enema (may not work)
2. Faecal softeners (Docusate sodium)
3. Bulk forming laxative (isphagula husk)

Manual evacuation (if severe as this outweighs the risk of perforation)

NOT STIMULANT LAXATIVES IN BOWEL OBSTRUCTION

Question 6

What patient factors might influence urinary continence?

Answer 6

Age
Weight
Obesity
Pelvic floor dysfunction
Childbirth/Pregnancy
Reduced mobility
Increased caffeine/fluids
Neurological conditions (Parkinson’s)
UTI

Question 7

What are the common types of urinary incontinence and explain them?

Answer 7

Stress Incontinence:
Involuntary leakage on exertion/stress

Urgency Urinary Incontinence:
Involuntary leakage accompanied with urgency

Mixed Urinary Incontinence is mic of SUI + UUI

Overflow Urinary Incontinence:
Chronic urinary retention where leakage of urine is due to a full bladder

Functional Urinary Incontinence:
Cognitive impairment, behavioural problems or mobility issues so can’t get to the toilet in time

Question 8

What are some medications that can cause urinary incontinence?

Answer 8

ACEi
Diuretics
Antidepressants
HRT
Sedatives

Question 9

What are some causes of urinary retention?

Answer 9

BPH
Constipation
Cancer/Tumour
Bilateral kidney stones
Anticholinergics
Neurological problems

Question 10

What non pharmacological interventions can be advised to improvise urinary incontinence?

Answer 10

Less caffeine
Less alcohol
Reduced fluid intake
Stop smoking
Avoid constipation

Question 11

What drugs are used to treat overactive bladder?

Answer 11

Oxybutynin hydrochloride - antimuscuranic

Mirabegon - B3 adrenoreceptor antagonist

Question 12

A elderly women is admitted after choking on her food, she has increasing cognitive impairment.

How would you establish her baseline + trajectory in function over the last 12 months?

Answer 12

Speak to family members/carers

The Abbreviated Mental Test Score
Mini Mental State Examination
Clock drawing
Behaviour before and now
Is she needing more assistance or care then before?

Question 13

What is the likely cause of poor oral intake in a patient with suspected dementia?

Answer 13

Depression
Muscle weakness/synchrony (dementia impairment in the swallowing centre in the brain)
Motor issues might mean they need help feeding

Question 14

What are the priorities in managing a patient with dementia?

Answer 14

SALT referral
OT/Physio referral
Set up agreed care plan with patient/family/carers/staff

Medical management:
Cholinesterase Inhibitors (Donepezil hydrochloride, Galantamine, rivastigmine)
CBT/SSRIs (depression)

Question 15

What types of fluid and food consistencies can be recommended by the SALT team?

Answer 15

Level 7 - Regular
Level 6 - Soft + Bitesized
Level 5 - Minced + Moist
Level 4 - Pureed
Level 3 - Liquidised

Question 16

Are there alternative feeding methods available and what is the evidence on the use of enteral (NG/PEG) feeding in patients with dementia?

Answer 16

Change texture of foods/drinks (softer foods/thicker drinks)
Moisten the patient’s lips and drink plenty of sips while eating

Enteral feeding:
Increased risk of aspiration pneumonia
No evidence that improves survival, weight or pressure ulcer healing
Can be distressing also

Question 17

What does the term “Feed at risk” mean? What information would be important to give with the family/next of kin when discussing this?

Answer 17

Patient continues to eat and drink despite risks of aspiration, choking and not meeting nutritional needs

Try and change consistency of meals, watch out for signs of aspiration pneumonia, ensure somebody is with the patient when eating if they choke

Question 18

What is mental capacity, why is it important to assess?

Answer 18

Your ability to interpret information and make informed decisions

Important to assess to see if you need to make a decision on the patient behalf

Question 19

What is a best interest decision? When is this made?

Answer 19

If a person has been assessed as lacking capacity then any action taken, or any decision made for, or on behalf of that person, must be made in his or her best interests

Question 20

What is an advance care plan? Who completes this and what is taken in consideration when completing this?

Answer 20

A patient sets out a plan of what they want there care to be in the future: what treatment they receive, where they will be cared for and where they will die

The patient chooses this in a progressive illness before they lack mental capacity

Question 21

What is a ReSPECT form and what do you understand about the discussions that should be held about this?

Answer 21

Recommended Summary Plan for Emergency Care and Treatment

Includes:
- patient diagnosis
- Preference of prioritising life vs comfort
- CPR attempts or DNAR
- Does patient have capacity to make decision

Should be with patient and doctor

Question 22

What are the common causes of falls?

Answer 22

Syncope falls (loss of cerebral blood flow causes LOC):
Cardiac arrhythmias
Postural hypotension
Aortic stenosis
Vasovagal syncope

Non-syncope falls:
Muscle weakness
TIA/Stroke
Infection
Incontinence
Hypoglycaemia
Environmental (poor walking aids/clutter)
Osteoperosis
Diabetic neuropathy

Question 23

What investigations would be helpful to assess if this patient had another cause for falling other than just an accidental fall?

Answer 23

ECG
BP (lying + standing)
General CVS exam

MSK Exam (incl gait)
PNS Exam
CNS/Visual assessment
FBCs, U+Es, CRP/ESR, blood glucose, CXR
DEXA scan

Question 24

What multidisciplinary interventions can be helpful when planning the discharge of an older patient who is at risk of falling?

Answer 24

Medic: treat underlying cause, ensure no medical issues leaving, ,meds review
OT: make adjustments at home, show them how to be more careful
Physio: help with muscle weakness

Question 25

What are the common consequences of falling?

Answer 25

Fractured hip
Rhabdomyolysis > AKI
Head injury

Question 26

What common prescribed drugs increase the risk of falls in older people?

Answer 26

Sedatives (benzodiazepines)
Anti-histamines
MAOI-B (Parkinson’s)
Anti-epileptics
Opioids
SSRIs
Anti-psychotics

Question 27

What are the common causes of acute confusion?

Answer 27

Infection
Hypoxia
Stroke/TIA
Hypoglycaemia
Alcohol poisoning or withdrawal

Question 28

What examinations/investigations should you order if somebody is acutely confused?

Answer 28

ABCDE
Blood sugars (BM)
CT Head/MRI Brain
FBC (CRP,ESR,WCC)
CNS Exam
Urine Dip
Stool culture
Blood cultures

Question 29

How would you manage a patient with acute confusion?

Answer 29

Hypoxia:
Give oxygen

Hypoglycaemia:
Give glucose gels or infusion

Infection:
Abx

Alcohol withdrawal:
benzodiazepines

Question 30

What’s first line for delerium?

Answer 30

Haloperidol

Question 31

What makes up the confusion screen on bloods?

Answer 31

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion