Palliative / Geriatric Medicine Flashcards
Medications causing postural hypotension:
Nitrates
Diuretics
Anticholinergic medication
Antidepressants
Beta-blockers
L-Dopa
ACEi
Drugs associated with falls due to mechanisms other than postural hypotension induction:
Benzos
Antipsychotics
Opiates
Anticonvulsants
Codeine
Digoxin
Sedatives
Who should receive an MDT assessment in terms of falls:
All patients over 65 with:
1 or more falls in the last 12 months
A fall that requires medical treatment
Poor performance or failure to complete Turn 180 test or the ‘Timed Up and Go’ test
What tests test for gait and balance abnormalities, and when should they be used in the context of a history of falls?
Timed Up and Go
Turn 180 TEST
Medical attention due to a fall
Recurrent falls in last year
Other risk factors for falls
What is included in a multifactorial risk assessment from a specialist falls service?
Assess for home hazards
Visual impairment testing and referral
Strength and balance training
Medication review with modification / withdrawal
Drugs with high anticholinergic burden (PC SOAP):
PC SOAP
Promethazine
Cetirizine
Solifenacin
Oxybutynin
Amitriptyline
Prochlorperazine
What will Advance Care Plans typically include?
Advance decision to refuse treatment - must be signed by the patient. Every medication not wanted must be written down.
DNACPR refers to cardiac or respiratory arrest. NOT legally binding.
TEP
Emergency care and treatment plans
Lasting Power of Attorney - legal document.
Which office oversees the LPAs?
Office of the Public Guardian oversees the LPAs.
An impartial witness must be present at the signing of these documents at the time of creation.
LPA for health and financial matters are separate forms.
A patient lacks capacity on an acute admission and advance care planning is needing to be discussed. Who should be sought in the absence of any family or friends?
Independent mental capacity advocate (IMCA)
What is a ReSPECT form?
Pre-emptive plan stating a person’s wishes for emergency medical care should they be unable to express them.
Recommended SUmmary Plan for Emergency Care and Treatment
Who are ReSPECT forms for?
Significant and complex medical histories and where capacity may absent in the near future.
Which scale is used to score frailty?
Clinical / Rockwood Frailty scale (CFS)
1= very fit
9 = terminally ill LE <6m
Which level of the CFS is completely dependent for all personal care?
7
But stable at not at high risk of dying.
https://rightdecisions.scot.nhs.uk/focus-on-frailty/clinical-frailty-scale-cfs/
Confirming a death (examination):
MINIMUM OF 5 MINUTES, confirm absence of:
Central pulse on palpation, carotide artery
Heart sounds on auscultation
Respiratory sound on ausculatation
Signs of life e.g. movement / respiratory effort
After 5 mins of cardiorespiratory arrest, confirm:
Bilateral absence of pupillary reflexes (will be fixed and dilated), corneal reflexes and supraorbital pressure trying to elicit motor response.
Documentation of confirmation of death:
Patient identification
Document each of the steps with the confirmed result
If the death needs to be referred to the coroner, discuss with a consultant and medical examiner.
If not, issue death certificate (MCCD).
Give an assessment tool used to assess patient’s prognosis and likelihood of survival if a patient is deteriorating:
Karnofsky Performance Status Scale
Within the palliative care phase of a patient’s life, there are multiple phases. List these 5:
Stable - adequate control
Unstable - urgent change in plan of care or emergency treatment is required
Deteriorating - periodic review required
Terminal - death is likely within days
Death - post death support provided to family/carers
5 key principles of the WHO analgesia ladder:
- oral administration where possible
- Regular intervals
- Prescribe according to pain characterised by the patient, free of clinician judgement
- Start at lowest dose
- Consistent administration is vital for effective pain management
WHO pain ladder:
- Non-opioids e.g. NSAID, paracetamol
- weak opioids e.g. codeine / dihydro, tramadol
- strong opioids e.g. fentanyl, morphine, oxycodone, methadone, buprenorphine
Adjuvants can be used at any step of the ladder, and these include antidepressants, anticonvulsants, corticosteroids and anxiolytics
4 drugs for the treatment of neuropathic pain (allodynia, hyperalgesia and paraesthesia):
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Pathways affected by TCAs:
Inhibit reuptake of serotonin and noradrenaline, increasing their effect.
Postsynaptic receptor antagonists of histamine, a-1 adrenoceptors and ach receptors, reducing their effects.
First line in trigeminal neuralgia:
Carbamazepine ; failure to respond or <50 years = neurology referral
Trigger factors e.g. light touch from washing shaving smoking
Red flags for trigeminal neuralgia;
Sensory changes
Deafness / other ear problems
Skin or oral lesions that can spread perineurally e.g. herpes
Pain only in ophthalmic division, OR bilateral
Optic neuritis
MS family history
<40 years
Oral to subcut morphine:
30mg oral = 15mg subcut
/2
Definition of malnutrition:
BMI <18.5
OR
unintentiaonl weight loss >10% in last 3-6 months
OR
BMI <20 and unintentional weight loss >5% in last 3-6 months
What score assesses a patient’s nutritional status and what does it include?
- BMI
- Weight loss score given
- Acute disease effect score
Identifies those at risk of malnutrition, or obesity.
Deprivation of liberty is related to human rights, and discussed in the Human Rights Act. The right to liberty is a qualified right, meaning the state can take this right away in certain circumstances. State these circumstances in a medical setting:
Lacks mental capacity
Under continuous supervision and control in a restricted space
The state participates in the patient’s care (NHS input)
These 3 must be present for a person to be deprived of their liberty by the state, via an independent legal process.
Deprivation of Liberty Safeguards are administered by a local authority / supervisory body. What 3 main assessments do they carry out as safeguards?
Mental disorder assessment
Mental capacity
Best interests - qualified best interest assessor
4 points required for capacity:
Understand information
Retain information
Use information to make a decision
Communicate their decision
Complications of malnutrition:
Impaired immunity
Poor wound healing
Growth restriction in children
Weight loss and loss of muscle mass
Multi-organ failure
Death
Electrolyte abnormalities in refeeding syndrome;
Hypokalaemia
Hypophosphataemia
Leading to cardiac complications and seizures
Triad of features in normal pressure hydrocephalus:
Urinary incontinence
Dementia and slowness of thought
Gait abnormality, similar to PD
Management of normal pressure hydrocephalus:
VP shunt
Significant complications can occur with this, including seizures, infection and intracerebral haemorrhage.
