Year 3 - Older Persons Medicine

Question 1

Name some issues older adults face?

Answer 1

Multiple co-morbidities
Cognitive impairment
Sensory deprivation (hearing and/or visual)

Question 2

What things should be asked in a Geriatric history?

Answer 2

Reason for admission.
Fall history (who, when, where, what, how)
Assessment of cognition (AMTS)
Continence assessment - bowels and bladder
PMHx, DHx (incl allergies),
SHx/Functional Hx = where they live, how they are supported, how they mobilise, who cleans/shops
Alcohol + Smoking
Further systemic enquiry (chest pain, s.o.b…)
Ask about their wishes and advanced directives if appropriate

Question 3

What is a Comprehensive Geriatric Assessment?

Answer 3

It is a multidimensional, interdisciplinary, diagnostic process to determine the medical, psychological and functional capabilities of a frail or older person in order to develop a coordinated and integrated plan for treatment and long-term follow up.

Results in better outcomes, reduced readmissions and reduced long-term care, greater patient satisfaction and lower costs

Question 4

What are the domains of a Comprehensive Geriatric Assessment?

Answer 4

Problem list - Current and Past
Medication review
Nutritional status
Mental health - cognition, mood, anxiety, fears
Functional capacity - basic activities of daily living, gait and balance, activity/exercise status, activities of daily living
Social circumstances - social network (visitors or daytime activities), informal support from friends/family
Environment - home environment, facilities & safety in the home, transport facilities, accessibility to local resources

Question 5

What are the main aims of discharge planning?

Answer 5

Reduce the persons length of stay in hospital,
Prevent an unplanned re-admission back into hospital,
Improve the manner in which community services co-ordinate following a discharge.

Question 6

What is a section 2?

Answer 6

Section 2 = Referral is made to Social services to assess funding, for example a care home, or direct payments (which people can use to buy in the personal assistance they require), or a package of care.
A social worker is then allocated to the patient and will be responsible for putting together an appropriate package of care.

Question 7

What is a section 5?

Answer 7

Section 5 = sent by Nursing staff to Social services, alerting them that the patient has been declared ‘medically stable for discharge’.
Once the section 5 is received the designated social worker is expected to start taking decisive action towards the discharge.

Question 8

What do discharges involve?

Answer 8

TTO’s - Medication to take home.
Transport.
Therapy assessment (community OT or Physio).
Restarting package of care - if complex or not in place then a section 2 may be involved to arrange.
Outpatient appointment.
District nurse referral or if required Palliative care.
Transfer back letter for residential/nursing home.

Question 9

Why do discharges fail?

Answer 9

One or more elements of the criteria under any one title have failed (a poor discharge).
Patient has health complications.
Communication breakdown (between healthcare professionals and social services).
Family decisions.
Decisions around funding.

Question 10

What is frailty?

Answer 10

Frailty = Condition characterised by loss of Biological Reserves and vulnerability to adverse outcomes.

Frailty is complex therefore solutions often need to be complex too = Comprehensive Geriatric Assessment

Question 11

How is the Frailty index score calculated?

Answer 11

Frailty index = (Number of deficits in an individual)/(Total number of deficits measured)

Question 12

How are falls broadly categorised?

Answer 12

Syncopal or Non-syncopal

Question 13

How would you take a history for falls?

Answer 13

How, Where, When, What, Who
How - How did they fall?
Where - Where did they fall? (eg shops/at home?)
When - When did they fall (at night? = vision issues?)
What - What happened before, during and after?
Who - Who witnessed the fall?
Before - Chest pains? Dizziness?
During - Tongue biting? Incontinence? Lose conscious?
After - Got themselves up? Weakness (eg stroke)?

Happened before? Medications? Normal mobility?

Question 14

What examinations should be performed for a fall?

Answer 14

Assessment of mobility
Cardiovascular examination - include ECG, lying and standing BP
Neurological examination
Musculoskeletal examination - assess joints (GALS)

Question 15

What is the definition of Delirium?

Answer 15

Delirium is an ACUTE CONFUSIONAL STATE, with a SUDDEN onset and FLUCTUATING course.

It develops over 1-2 days and is recognised by a change in consciousness either hyper- or hypoalert and inattention.

Question 16

List some possible causes of Delirium

Answer 16

THINK - T = Toxic (CHF, Shock, Medications)
H = Hypoxaemia 
I = Infection
N = Non-pharmacological treatments
K = K+ and other electrolytes

Also consider drugs/Opiates, Urinary retention, Constipation, uncontrolled Pain.

Question 17

What are the consequences of Delirium?

Answer 17

Prolonged hospital stays,
Increased mortality,
Higher rates of complications,
Increased risk of developing dementia.

Question 18

What are the categories of Delirium?

Answer 18

Hyperactive (agitated and confused),
Hypoactive (withdrawn and drowsy),
Mixed.