Older persons medicine lecture Flashcards
What is carer strain?
- When family member cares for another family member and this becomes overwhelming leading to stress, depression and ill physical health
- Often as private care is expensive
Falls history
- When and where
- Frequency, time course - how many falls within last 12 months?
- What was the patient doing just before? - change of posture? head movement/bending? turning?
- What happened after?
- Get witness report - ask
- Be cautious with ‘I tripped’ and ‘blackout’
- If fall in toilet at night - often due to postural drop
Red flags for falls
- Loss of consciousness
- New confusion
- Trauma to head
- Vomitting
- Incontinence
- Seizure activity
Definition of recurrent falls
More than 2 within last 12 months
If someone does not lose consciousness, how do they fall?
Have protective mechanism - reach out arms eg wounds on hands
Those who don’t - just hit the ground, could have nose fracture or head wound
Who can you contact for urgent review of home for falls risk?
- Intensive community support team
- Have OT, physio and nurses - assess and prevent admission
Financial threshold for carers being funded?
If you have £25,000 of savings - you will have to pay for carers
Below this they are government funded
Inv for falls and management general
- Look for injuries - body map, WHOLE body
- ECG
- Lying and standing BP
- Medication review - polypharmacy = 5 and above
- Gait/functional assessment
- Bone health review
- Fear of falling/loss of confidence - ask about this
- Exercise program - strengthen muscles and teach how to fall
If on 3 or more BP tabs, do they have compliant issues?
Key components of CGA
- Medical - problem, co-morbids, meds, nutrition
- Functional - activities of daily living, gait and balance, exercise
- Psychological - cognitive status, mood
- Social - informal social support?
- Environmental - home safety, care resource eligibility, access to transport
If change in environment occurs, can make changes in elderly more obviou
Clinical frailty score
If 6 and above - see by geriatrician for advanced care planning and review
When is POA valid?
When someone is determined to have lost their capacity
Otherwise they make the decision themselves
(originally signed when has capacity with solicitor)
What does someone have to lack to be deemed lacking capacity?
They will lack the ability to:
* Understand information given about specific decision
* Retain information long enough to make decision
* Weight up information
* Communicate decision
Capacity can be…
- Fluctuant
- Decision specific for that decision alone at that point of time
Safeguarding - what is it
- Measures to protect health, wellbeing and human rights of individuals
- Allows people - esp children, young people and vulnerable adults to live free from abuse, harm and neglect
- Concerns can be raised to either local safeguard team or social services
- If crime been comitted may need police input
Types of fluids and foods - SALT
What is feed at risk?
- Person continues to eat and drink despite significant risk of aspiration/choking
- Ensures QOL - highest priority
- Allows continued enjoyment, comfort, pleasure and social interaction
When is feed at risk more appropriate?
- Advanced stage of illness
- Swallow safety not likely to improve
- Preference is to eat and drink over swallow safety
- Tube feeding is declined/inappropriate
What can you do if you are concerned about a patient at home who does not need acute hospital admission but cannot cope at home alone?
- Community hopsital admission can be considered
What is DTA bed? - discharge to assess
- Bed in care home
- Funded by council - first 4-6 weeks
- Then observed by community team - will have MDT whether need care home or can go home
- If need to be care home - will assess funding needs
Nursing home vs residential home
- Nursing home - staffed by nurses, eg if PEG feed needs, advanced dementia, more expensive
- Residential home - staff are trained but not in nursing care
Referral for ?dementia
Memory clinic
Prognosis if needing to be admitted to nursing home
18 months - 2 years
Tips for OSCE
- Use every second - write down differentials at start and structure
- Make sure ask about differentials specifically to eliminate them - eg if suspect PE - ask about haemoptysis, stroke ask about weakness
- Every sentence means something in the exam
What medication in elderly can cause GI bleed?
Sertraline
What is the definition os postural drop?
- Reduction in 20mmHg systolic or more on standing
- Or reduction in 10 mmHg diastolic or more
- Should also check have symptoms to diagnose
How to perform lying and standing BP?
- Lie down flat for 5 minutes - measure
- Stand up - feel ok?
- Measure BP 1 minute after standing
Measure at 3 mins after standing
What should yoiu encourage when in hospital?
- Independence
- Own routine
- Can encourage wearing of own clothes - look a lot more well
What is medication for postural drop?
- Fludrocortisone - increases BP, is a mineralocorticoid so increases fluid retention
- CAUTION in HF - can cause pulmonary oedema (will cancel out furosemide)
Prescribing medications in elderly
- Caution when over 5 meds
- Consider removing a medication if a new one is needed
- Use STOPP/START
- Start low and go slow
Most useful inv for incontinence
Post void bladder scan - check for overflow incont
When to refer to cystoscopy?
- Painless haematuria
When is urine dipstick useful in elderly?
- For haematuria and proteinuria
- Not useful for infection
Continence assessment inv
- Detailed history
- Bladder and bowel diary
- Abdo exam
- Urine dip and MSU
- PR exam inc prostate assessment in male
- External genitalia review - look for atrophic vaginitis in females
- Post micturition bladder scan
How much sirloin steak (250g) of muscle mass do people lose if people bed bound for 1 week?
Lose one sirloin steak every day
= 6 steaks (ish) per week
Management of incontinence
- Decaff drinks
- Good bowel habits
- Improve oral intake - but stop drinks 4 hrs before bed time
- Regular toileting
- Pelvic floor exercises and bladder training
- Anticholingerics not good in elderly (esp oxybutynin)
- Postural drop can occur from drugs used for incontinence
- Drug therapy and pads are NOT first line
Anticholinergic side efefct
- Dry mouth
- Dry eyes
- Blurred vision
- Confusion
- Urinary retention
Fragility fracture define
- Fracture from falling from standing height or lower at walking speed or slower
- Occur most in spine (vertebrae), hip (proximal femur) and wrist (distal radius)
Seeing fragility fracture on x-ray vs pathological fracture
- May be evidence of osteoporosis - lucent areas within bone, transparent
- Pathological fracture - lucency with blurry margin and dense white colour
OP bloods
Normal
When to assess OP of patients and how?
- All women aged 65 years and over
- All men aged 75 and over
If under these ages with RF below, investigate with FRAX:
* previous fragility fracture
* current use or frequent recent use of oral or systemic glucocorticoids
* history of falls
* family history of hip fracture
* other causes of secondary osteoporosis
* low body mass index (BMI) (less than 18.5kg/m2)
* smoking
* alcohol intake of more than 14units per week for women and more than 21units per week for men
FRAX score and management
- Green - lifestyle advice and reassure, reasses 5 years- exercise, balanced diet
- Amber - DEXA scan to check BMD, recalculate risk
- Red - give bisphosphonate straight away
Management of OP - medicine
FINSISH
- Check vitamin D, calcium level and renal function first (>30)
- Bisphosophate (oral) - alendronic acid
- Takes 6-12 months to work
- Warn re osteonecrosis of jaw - rare
Bisphosphonate will lower calcium so check!!!
Hypocalcaemia symptoms
- Tingling
- Muscle spasms
- Tetany
- Cardiac arrhythmia - prolonged QT
How to advise someone to take alendronic acid
- Take first thing in the morning - on empty stomach (compete for protein receptors)
- Sit upright and no food for 30 minutes
- With large glass of water - due to risk of oesophagitis and perforation
Alternative options if someone will find oral bisphosphonate difficult (eg if vomitting, GI ulcers or cognitive impairment)
- IV zolendronate
- One off per year - 30 minute
- Ensure calcium, vitamin D and renal function ok
- Check teeth post infusion –> dentist review?
Alternative to bisphosphonate if CrCl <35 or eGFR low <30 or if intolerant to IV and oral bisphosphonates
- Denosumab
- MAB
- Inhibits osteoclasts, decreases bone resorption, increases BMD
- SC injection once every 6 months
- Risk of ONJ and stress fractures
When not to operate on hip fracture?
- Rarely not operate - only if dying
- Outcomes are better earlier on
- If infection, give 48hrs abx then operate
- If have hip fracture - it is a prognostic sign, 50% die within nect year
Why operate on hip fracture?
- Ensure pain control
- Reduce opioid requirements
- Allow good nursing care
- Allow sitting out
- Allow chance to regain function
NICE guidelines of CT head scan following head injury
Causes of delirium
THINK DELIRIUM
* Trauma
* Hypoxia (PE, CCF, MI)
* Increasing age
* Neck femur fracture
* SmoKe or alcohol withdrawal
* Drugs stopped
* Environment - ward moves
* Lack sleep
* Imbalanced electrolytes
* Retention - urinary or constipation
* Infection/sepsis
* Uncontrolled pain
* Medical conditons - delirium, parkinsons
Management of dementia reduced feeding and weight loss
- Hand feed blended normal foods
- Not suitable for PEG
Asisstance for feeding in hospital
Red tray/red lid to jug
MUST score
Which delirum more concerning?
Hypoactive - longer hosp stay, higher mortality and morbidity rate
Common areas for pressure sores
- Sacrum
- Heels
- Elbows
- Ears
RF for pressure sores
Waterlow
* Low BMI
* Broken skin/oedematous
* Older
* Losing weight
* Incontinence problem
* Co-morbidities
Grading of pressure sores
Management of pressure sore
- Prevention
- Wound management - dressing changes, manage pain
- Friction reduction
- Nutrition - protein to speed up healing
- Pressure redistribution and repositioning
If someone does not have capacity, what is DOLS?
- Deprivation of liberty safeguards
- Legal document
- Allows clinicans to make decisions in patients best interest
Dishcarge destinations for patients
- Own home (+POC)
- Community hospital
- Specialist accomodation (Warden control) - warden can come and help if necessary, independent
- Discharge to assessment bed - if max POC and may need care home
- Residential home
- Nursing home - if need more nursing needs eg PEG tube, catheter, parkinsons
- Fast track - life expectancy less than 6 weeks
