Older Persons Medicine (geriatrics/palliative care/stroke medicine) Flashcards
What are some causes of constipation in an older patient?
Dehydration
Low-fibre diet
Sedentary lifestyle (post operation)
Diabetes-induced
Polypharamacy
Dementia/parkinson’s
electrolyte imbalances (hypok, hyperca, hypermg)
Link to depression
What examination would you undertake in an elderly patient with constipation?
Abdominal exam
DRE
What medications can affect the bowels?
Constipation:
Opoids
NSAIDs
Antipsychotics
Antidepressants
Antihistamines
Ca channel blockers
Diarrhoea:
PPIs
Abx (C.diff)
What investigations would you do in somebody with constipation?
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
How do you manage severe constipation?
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
What patient factors might influence urinary continence?
Age
Weight
Obesity
Pelvic floor dysfunction
Childbirth/Pregnancy
Reduced mobility
Increased caffeine/fluids
Neurological conditions (Parkinson’s)
UTI
What are the common types of urinary incontinence and explain them?
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
What are some medications that can cause urinary incontinence?
ACEi
Diuretics
Antidepressants
HRT
Sedatives
What are some causes of urinary retention?
BPH
Constipation
Cancer/Tumour
Bilateral kidney stones
Anticholinergics
Neurological problems
What non pharmacological interventions can be advised to improvise urinary incontinence?
Less caffeine
Less alcohol
Reduced fluid intake
Stop smoking
Avoid constipation
What drugs are used to treat overactive bladder?
Oxybutynin hydrochloride - antimuscuranic
Mirabegon - B3 adrenoreceptor antagonist
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?
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?
What is the likely cause of poor oral intake in a patient with suspected dementia?
Depression
Muscle weakness/synchrony (dementia impairment in the swallowing centre in the brain)
Motor issues might mean they need help feeding
What are the priorities in managing a patient with dementia?
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)
What types of fluid and food consistencies can be recommended by the SALT team?
Level 7 - Regular
Level 6 - Soft + Bitesized
Level 5 - Minced + Moist
Level 4 - Pureed
Level 3 - Liquidised
Are there alternative feeding methods available and what is the evidence on the use of enteral (NG/PEG) feeding in patients with dementia?
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
What does the term “Feed at risk” mean? What information would be important to give with the family/next of kin when discussing this?
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
What is mental capacity, why is it important to assess?
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
What is a best interest decision? When is this made?
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
What is an advance care plan? Who completes this and what is taken in consideration when completing this?
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
What is a ReSPECT form and what do you understand about the discussions that should be held about this?
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
What are the common causes of falls?
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
What investigations would be helpful to assess if this patient had another cause for falling other than just an accidental fall?
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
What multidisciplinary interventions can be helpful when planning the discharge of an older patient who is at risk of falling?
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
What are the common consequences of falling?
Fractured hip
Rhabdomyolysis > AKI
Head injury
What common prescribed drugs increase the risk of falls in older people?
Sedatives (benzodiazepines)
Anti-histamines
MAOI-B (Parkinson’s)
Anti-epileptics
Opioids
SSRIs
Anti-psychotics
What are the common causes of acute confusion?
Infection
Hypoxia
Stroke/TIA
Hypoglycaemia
Alcohol poisoning or withdrawal
What examinations/investigations should you order if somebody is acutely confused?
ABCDE
Blood sugars (BM)
CT Head/MRI Brain
FBC (CRP,ESR,WCC)
CNS Exam
Urine Dip
Stool culture
Blood cultures
How would you manage a patient with acute confusion?
Hypoxia:
Give oxygen
Hypoglycaemia:
Give glucose gels or infusion
Infection:
Abx
Alcohol withdrawal:
benzodiazepines
What’s first line for delerium?
Haloperidol
What makes up the confusion screen on bloods?
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
