Older Persons - Presentations Flashcards
What is syncope?
A transient loss of consciousness (TLoC) due to cerebral hypoperfusion, characterised by rapid onset, short duration, and spontaneous complete recovery.
What are the causes of syncope?
- vasovagal syncope (emotional or orthostatic trigger)
- hypovolaemia
- cardiac arrhythmias
- acute coronary syndrome
- pericardial tamponade
- vascular steal syndrome
- substance abuse
- anxiety
What questions should be asked in TLoC history/
- was loss of consciousness complete?
- how quickly did it come on and how long did it last?
- was there any warning (e.g. light-headedness, nausea, sweating)
- accompanying chest pain or SOB?
- was recovery spontaneous or total?
- has there been a recent change in medication?
How should a patient be examined following a syncopal episode?
- blood pressure (drop of 20mmHg systolic lying»_space; standing = orthostatic hypotension)
- cardiovascular examination
- ECG
- FBC
- random plasma glucose
- respiratory examination
What are some differentials for TLoC?
- syncope
- falls
- epilepsy
- narcolepsy
- dizziness
- TIA / stroke
What are some risk factors for falls?
- age > 80 years
- female gender
- low weight
- previous falls
- dependency in activities of daily living
- orthostatic hypotension
- medication
- diabetes mellitus
- disturbed vision
- cognitive impairment
- gait disorders
- inappropriate footwear
What questions should you ask when doing a falls history?
- was the fall an isolated event?
- what caused the fall?
- what was you doing at the time?
- was there any loss of consciousness?
- was there any warning before the fall?
Following a fall, how should an elderly person be assessed?
- mental state examination
- neurological examination
- visual impairment
- cardiovascular examination
What tests can be used to predict the risk of an elderly person falling?
Timed Up and Go Test (TUGT): patient rises from a chair without support of their arms, walk three meters, turn round and sit again. Completion of the test without unsteadiness suggests a low risk of falling.
Turn 180° test: request the patient stands and steps around until they are facing in the opposite direction. If more than 4 steps are required to do this, it is suggestive of a high risk of falls.
How can falls be prevented?
- home assessment and interventions
- exercise to maintain power and balance
- reduce alcohol intake
- reviewing medications
What is constipation?
Defecation that is infrequent (<3 times weekly), difficult or incomplete.
Presentation of constipation in the elderly.
- confusion or delirium
- nausea
- loss of appetite
- overflow diarrhoea
- urinary retention
What are the risk factors for constipation?
- inadequate dietary fibre
- inadequate fluid intake
- lack of exercise
- anxiety
- drug treatment
Give some causes of constipation.
- low fibre
- elderly age
- post-operative pain
- rectal prolapse
- colorectal carcinoma
- pseudo-obstruction
- hypothyroidism
- opioid analgesics
- spinal nerve injury
How should a patient with constipation be investigated?
- FBCs
- U&Es
- Ca2+
- TFTs
- sigmoidoscopy
Management of constipation.
Treat the cause and mobilise the patient.
Conservative measures include increasing fluid intake and fibre.
Bulk producers, osmotic agents or stool softeners can be used to manage constipation if other measures fail.
What are the types of incontinence?
Stress incontinence - small volumes leak during coughing or laughing.
Urge incontinence - frequent voiding, cannot hold urine. Commonly seen with detrusor overactivity.
Overflow incontinence - due to urinary retention. Seen with a mix of obstructive symptoms.
Functional incontinence - often due to cognitive impairment or behavioural problems.
What is required for continence examination?
- review of bladder and bowel diary
- abdominal examination
- urine dipstick and MSU
- PR examination
- external genitalia review
- post-micturition bladder scan
What are the conservative measures that we can use to control continence?
- decaffeinated drinks
- good bowel habit
- improving oral intake
- regular toileting
- pelvic floor exercises
- bladder retraining
What medication is often given for urge incontinence?
Oxybutynin - anticholinergic.
Good for managing urge incontinence in younger patients, but due to side effect profile of postural hypotension, falls risk increases so ?not appropriate for elderly patients.
What are the causes of faecal incontinence?
- spinal injury (?anal tone laxicity)
- urinary retention
What is delirium?
An acute confusional state, with a sudden onset and fluctuating course.
What are the causes of delirium?
D - Drugs
E - Electrolyte imbalances
L - Liver failure / Low O2
I - Infection
R - Retention (urinary or faecal)
I - Intracranial haemorrhage / stroke / TIA
U - Uremia
M - Metabolic (hypoglycaemia, dehydration)
What are the associations of delirium?
- increased mortality
- prolonged hospital admission
- higher complication rates
- increased risk of dementia
What are the types of delirium?
Hyperactive delirium - patient is agitated and confused.
Hypoactive delirium - patient is withdrawn and drowsy.
Mixed.
What is dementia?
A progressive decline in cognitive function, occurring across several months. It affects many areas of function including:
- retention of new information
- managing complex tasks
- language and word finding difficulty
- behaviour
- orientation
- ability to self care
- recognition
What is the most common type of dementia?
Alzheimer’s - insidious onset with slow progression, with behavioural problems typical. Diagnosed on clinical history but brain imaging may show disproportionate hippocampal atrophy.
What is vascular dementia?
Dementia caused by multiple cerebrovascular events causing ischaemic damage to the brain, having a stepwise progression.
What are the treatment options for Alzheimer’s?
Cholinesterase inhibitors to slow its progression.
For most other types of dementia, there are no treatment options and the only management is to control risk factors to slow progression.
