Yr4 Geriatrics - Lectures Flashcards
What is the definition of Stroke?
- What are the 4 possible pathophysiologic processes causing stroke?
Stroke = Neurological injury as a result of disruption of blood supply by embolism, thrombosis, atheroma or haemorrhage.
Stroke
- 4 Types of Infarct?
- 4 Types of Haemorrhage?
INFARCT
1. Thrombus
2. Embolus
3. Lacune
HAEMORRHAGE
1. Subarachnoid –aneurysm
2. Intra parenchymal – hypertension
3. Sub-dural
4. Extra dural
List 19 Differentials for Acute Stroke?
What are the 4 Stroke Clinical Syndromes and the clinical features you would expect to see in each?
Where is the lesion if:
- Pure motor?
- Pure sensory?
- Sensorimotor?
- Ataxic hemiparesis?
- Hemiballismus?
- Hemiballismus = a hyperkinetic involuntary movement disorder characterized by intermittent, sudden, violent, involuntary, flinging, or ballistic high amplitude movements involving the ipsilateral arm and leg caused dysfunction in the CNS of the contralateral side.
- Dysphasia if dominant hemisphere and visuospatial problems if in non-dominant hemisphere
- What defines your dominant hemisphere = the one with speech, handedness does not necessarily correlate
- Rare to have a dominant right hemisphere
- Homonomous hemianopia and ipsilateral motor/sensory (same side as the homonymous hem not same side as the lesion
- Eg. If you have a left hemisphere (dominant) stroke = loose speech, right homonomous hemianioia & right sensory/motor deficits
What is the definition of a TIA?
TIA is a transient episode of neurologic
dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.
- Embolic TIA, which may be artery-to-artery, or due to a cardioaortic or unknown source.
- Lacunar or small penetrating vessel TIA.
- Large artery, low-flow TIA
What is involved in the clinical assessment of someone with suspected stroke? (7)
CLINICAL ASSESSMENT
1. MOBILITY
2. BALANCE
3. SWALLOWING
4. SPEECH
5. SENSATION
6. VISION
7. SPATIAL/PRAXIS
Outline the management principles for stroke.
- Acute?
- Secondary Prevention - 6 Risk Factors?
- 6 Complications?
Secondary Prevention
Risk Factors:
1. Atrial fibrillation or cardiac disease
2. Hypertension
3. Dyslipidaemia
4. Diabetes
5. Smoking
6. Carotid stenosis
Treatment
- Aspirin or anticoagulation
- Treat risk factors
What is the definition of a Comprehensive Geriatric Assessment (CGA)?
- What influences the health of older people?
Definition - Comprehensive Geriatric Assessment (CGA)
- The detailed evaluation of the medical, functional and psychosocial status for older people.
- Considers environmental resources.
- Can lead to more accurate diagnosis and improved outcomes such as reductions in functional decline and use of hospital services (compared to usual care).
- Not every older person needs or has the characteristics to benefit from CGA.
WHO Definitions
- Disease?
- Impairment?
- Disability?
- Handicap?
- Disease—an intrinsic pathology or disorder . . . [which] may or may not make [itself] evident clinically.
- Impairment—a loss or abnormality of structure or function at the organ system level.
- Disability—a restriction or lack of ability to perform an activity in a normal manner, a disturbance in the performance of daily tasks.
- Handicap—a disadvantage resulting from impairment or disability that limits or prevents fulfillment of a role that is normal.
Who typically benefits from a Comprehensive Geriatric Assessment (CGA)?
- List 7 Benefits of CGA?
Who typically benefits?
- Not every older person needs or has the characteristics to benefit from CGA.
- Older people with complex medical conditions, significant physical disability, cognitive impairment and precarious social supports.
Which multi-dimensional teams might be involved in a CGA? (6)
Multi-dimensional assessment & Multidisciplinary evaluation
- Comprehensive Geriatric Assessment is always a multidimensional process and (depending on available resources) is often multidisciplinary in nature.
- ‘Usual health care’ focuses on the diagnosis and treatment of medical problems.
- CGA focuses on older people with complex bio-psychosocial problems, and places great importance on functional status and quality of life.
Multidisciplinary assessment that may involve:
1. Medical
2. Nursing
3. Physiotherapist
4. Occupational therapist
5. Social worker
6. Others – dietitian, pharmacist, speech therapist, psychologist, GP, other specialists
Who should be targeted for a CGA? (10)
When older persons come into a hospital, risk screening for which conditions should be performed? (4)
Outline the Components of a GCA?
Outline the history you would take as part of a Comprehensive Geriatric Assessment (GCA)? (8)
GCA - History
- Information sources: Patient, family/friends/carers, medical record, GP/other doctors, healthcare professionals, care providers, direct observation.
- Key components (beware factors affecting reliability):
1. History of presenting problem
2. Past and current medical history
3. Premorbid function (physical and cognitive)
4. Medications (current and discontinued) and allergies
5. Dietary history
6. Social history (include physical environment)
7. Advance care planning (EPA/EPG/ AHCD)
8. Collateral history (informant interview)
List the Key Domains of the Functional assessment in a CGA?
- What are ADLs? Examples?
- Instrumental ADLs? 7 Practical Examples?
Instrumental Activities of Daily Living (IADLs)
- Those activities that allow an individual to live independently in the community.
- The ability to perform IADLs can significantly improve QOL.
- IADLs commonly confused with basic ADLs (mobility, dressing, bathing, feeding). In contrast with IADLs, ADLs are more basic tasks that are necessary for basic functional (independent) living.
- Deficits in performing ADLs usually indicate a need for home care or residential placement.
- IADLs include cooking, cleaning, transportation, laundry, managing finances. These are more complex
tasks that are still a necessary part of day to day life.
Practical Examples of IADLs
1. Using the telephone to communicate with others.
2. Shopping for groceries alone.
3. Planning, heating/cooking, serving own meals.
4. Managing own medications.
5. Cleaning own home.
6. Getting around on your own (by car, bus, taxi, public transport).
7. Managing money and paying bills.
Outline 2 Functional Assessment Tools that may be used in a CGA?
- Barthel ADL Index
- Functional Independence Measure (FIM)™
CGA - Functional Assessment Tools
- Outline the components of the Functional Independence Measure (FIM)™?
What common things should you look for on examination in a CGA? (8)
- List 7 Commonly used CGA instruments?
CGA - Examination
1. General (includes appearance, cleanliness, wasting, behaviour, dentition)
2. Frailty
3. Mental state (conscious state, mood, psychotic Sx, thoughts)
4. Hearing and vision
5. Neurological (full neuro is part of a CGA) – absent ankle jerks or decreased vibration sense can be normal in older people
6. Musculoskeletal
7. Cardiovascular (include postural BP)
8. Nutrition (evidence of muscle wasting or weakness, calculate BMI)
What is the 4AT?
4AT - Delirium Screening Tool (2011)
- Short and simple
- No training needed
- Built-in cognitive testing
- Good sensitivity and specificity
- Detects delirium at the expected level
- No registration or permissions needed (unlike MMSE and MoCA)
- Main delirium detection tool used in practice in many countries.
List 5 Screening Tools for Cognitive Assessment?
- Components of the MMSE?
Cognitive Assessment
LEARNING and MEMORY, LANGUAGE, EXECUTIVE FUNCTION, PERCEPTUAL-
MOTOR FUNCTION, SOCIAL COGNITION, COMPLEX ATTENTION (6 domains)
1. MMSE - Mini-Mental State Examination
2. MOCA - Montreal Cognitive Assessment
3. RUDAS - Rowland Universal Dementia Assessment Scale (CALD)
4. AMT - Abbreviated Mental Test (10 item, 4 item)
5. KICA - Kimberley Indigenous Cognitive Assessment Screening Tools
Components of the MOCA?
Is it better or worse than MMSE for detecting early cognitive decline?
What is the Geriatric Depression Scale (GDS)?
Which investigations would you consider as part of a CGA? (10)
- What is the overall purpose of a CGA?
Investigations
- No routine blood or radiological tests for a CGA
- Consider (if indicated):
1. U&Es
2. FBE
3. LFTs
2. Glucose
2. TFTs
3. Vit D
2. B12, folate
3. Urine (dipstick, MCS)
4. ECG
5. CXR
What are some of the common issues identified during a CGA? (7)
- Outline the principles of management for issues (5).
Management Plan
- Developing person-centred goals (SMART)
- Often involves a family meeting.
- A CGA often reveals multiple issues.
- Common examples:
1. Sub-optimally managed medical problems
2. Polypharmacy (including medication side effects and drug interactions)
3. Functional impairments
4. Geriatric syndromes (frailty, dementia, falls, incontinence, pain)
Define Rehabilitation.
- What is the purpose of Aged Care Rehabilitation?
- What does it involve? (3)
What is MyAgedCare? What are the 2 types of assessment it offers?
What are the Geriatric Syndromes/Giants?
- Define a Syndrome.
- 4 Geriatric Giants?
- 5Ms?
Geriatric Syndromes
- “Syndrome”: recognizable set of symptoms and signs which indicate a specific condition for which a direct cause is not necessarily understood. Does not fit into a discrete organ-based disease category.
- Recognition of the importance of other syndromes affecting older persons such as frailty and polypharmacy.
- Geriatric Giants (1965, Isaacs):
1. Immobility
2. Instability (falls),
3. Incontinence
4. Impaired intellect/memory (including delirium and dementia).
What is Frailty?
- What is the frailty phenotype? (5)
Frailty, a clinical syndrome
- Defined by ANZSGM Position Statement 22 ’Frailty in Older People’
- The term frail is intended to identify vulnerable older people at high risk of adverse outcomes including falls, worsening disability, institutionalisation and death.
- Frailty is not synonymous with either age or disease.
- Conceptualised as an age-related syndrome of physiological decline characterised by an increased vulnerability to adverse health outcomes.
- Frailty may coexist with chronic disease, multimorbidity, and/or disability – but does not need to.
- Clinical frailty scales exist – but clinical impression is often the best way to identify a frail older person.
- Definition still contentious.
Outline 2 clinical frailty scales.
What is Delirium?
- A to E?
- Delirium is a syndrome.
- Family or friends may say the patient is “not normal”, “confused”, can’t concentrate.
- Patients may say: “I don’t feel quite right” “I can see funny things on the walls” “Where am I again?”
- Patients may be confused, hit out, or do nothing.
- Behaviours can change from hour to hour, day to day.
- This condition has had many different names including acute confusional state, metabolic encephalopathy and acute organic brain syndrome. The term delirium has largely replaced these.
What are the 9 hallmark features of Delirium?
- Acute/subacute onset (hours/days).
- Fluctuation (symptoms come/go, or vary in intensity over the day).
- Decreased attention (distractible, cannot focus or shift).
- Altered level of consciousness (hyper alert versus drowsy versus difficult to rouse versus unrousable).
- Disorganised thinking (may be rambling, tangential, incoherent).
- Altered sleep-wake cycle.
- Perceptual disturbance– may have visual hallucinations or delusions (typically persecutory, may be grandiose).
- Emotional deregulation (anxiety, fear, irritability).
- Psychomotor disturbance.
What are the 3 Types of Delirium?
- Hyperactive
- Mixed! (most common)
- Hypoactive!
- More common in older people.
- Often missed.
- Has a worse prognosis than other subtypes of delirium, including worse long-term cognition when delirium has a longer duration.
What are 6 Red Flags for Delirium? (Patients at high or increased risk of delirium)
- Patients aged 65 and older
- With known cognitive impairment
- With known dementia - One of the strongest, most consistent risk factors. Underlying dementia is present in 25-50% of patients. Presence of dementia increases risk of delirium by a factor of 2-3 x.
- With a hip fracture
- Those who are severely ill or at risk of dying
- Previous episode(s) of delirium.
Who should be screened for delirium?
- What collateral history should be obtained?
Assess for delirium in:
- Patients with cognitive impairment on presentation to hospital.
- Patients who have a sudden decline in cognitive function or change in behaviour during their hospital admission.
- Delirium is less likely to be recognised in patients with frailty or dementia.
What screening tools are available for Delirium?
- What is the AMT?
- AMT4?
Screening Tools
1. Abbreviated Mental Test score - Traditional AMT (10 questions) + AMT4
2. 4A test (4AT)
3. Single Question in Delirium (SQID) - (asking family or friend): Do you
think [name of patient] has been
more confused lately? Yes/No answer
4. Confusion Assessment Method
NOT
* Mini Mental State Examination
* Montreal Cognitive Assessment (MoCA)
What is the best validated delirium screening tool?
- 4 Components?
4AT components - Four sections
1. Alertness
2. AMT4
3. Attention
4. Acute change or fluctuating course
Score out of 12, anything greater than 4 is abnormal, anything 1-3 possibly abnormal.
What is the Confusion Assessment Method (CAM)?
- 4 Components?
- If features 1 and 2 present AND
- Feature 3 OR 4 present
- Delirium present according to CAM.
- Serial assessments can track progress/recovery.
- A large (N=785) RCT comparing the 4AT and the CAM found that the 4AT had higher sensitivity than the CAM, and a similar specificity.
How common is Delirium?
Why is it important?
Epidemiology of Delirium
- 10 - 31% of new hospital admissions.
- Up to 30% of medical patients >65 years will develop delirium during hospital admission.
- Prevalence in ICU patients up to 80%.
- Prevalence of post-operative delirium: 5-10% general surgery, 50% orthopaedics.
- Around 80% will develop delirium near death.
- In hip fracture patients, delirium can occur in up to 53.3%.
- In patients aged 70 and over, up to 18% will develop delirium during admission.
Why is a diagnosis of delirium often missed?
- 3Ds?
Dementia
- Delirium can be mistaken as worsening of dementia.
- Delirium should still be treated!!!
Psychiatric Illness
- Hypoactive delirium can be mistaken as depression.
- Agitation and hallucinations can be mistaken as schizophrenia.
List some of the causes of Delirium.
- Sepsis and infections (especially chest and urine)
- Hypoxia
- Constipation
- Medications
- Alcohol and nicotine withdrawal
- Uncontrolled pain
- Surgery/procedures
- Sleep deprivation
- Disorientation (e.g. constant bed moves)
- Sensory deprivation (e.g. loss of
glasses/hearing aids)
Delirium Evaluation?
- Which investigations?
Delirium Evaluation
1. Suspect
2. Recognise
3. History (including medication review) - Collateral important.
4. Physical examination (including neurological) - May not be cooperative.
5. Investigations - ‘Normal’ investigations do not exclude delirium.
How can we try to prevent delirium?
- Examples?
Delirium Prevention
- Preventative measures can reduce delirium incidence.
- 30 – 40% of delirium cases in hospital can be prevented.
- A non-pharmacological, multi disciplinary approach (environmental strategies) has been shown to reduce the incidence, duration and severity of delirium.
- Little evidence for pharmacological strategies to prevent delirium.
What are the 2 Treatment Principles of Delirium?
- What are we trying to achieve? (6)
TREATMENT PRINCIPLES
1) Protect/support the patient
2) Treat any underlying cause(s)
What are we trying to achieve?
1. Prevent injury
2. Prevent falls
3. Avoid pressure injuries, malnutrition, dehydration.
4. Continue appropriate treatment
5. Enhance recovery.
6. Return to normal function.
What is involved in the treatment of delirium in terms of 1) supporting the patients?
- Communication strategies?
- MDT?
- Environment?
Everyone has a role in management of delirium (multidisciplinary team).
- Good nursing care,
- medical review for complications,
- mobility with physiotherapy,
- dietician review for nutrition,
- speech pathology review for swallow, etc.
Environment
- Direct vision room (near the nurses’ station).
- Delirium unit/pod.
- Appropriate noise (keeping it quiet may help)
- Appropriate lighting (well lit)
- Single room if possible.
- Familiar objects.
- Clear signs (day, time, place)
- Low bed?
What does the pharmacological management of delirium involve?
- Which agents should NOT be used?
- Risks?
Caution
- Use medication only if patient is distressed or there are behavioural risks
- Avoid benzodiazepines because they generally worsen delirium and may cause falls
- Antipsychotic medications are not a fir st line option and should be used with caution because of an association with strokes and adverse cardiac events
Outline the normal recovery from delirium.
What is the definition of Urinary Incontinence?
- How common is it?
THE COMPLAINT OF
ANY INVOLUNTARY
LEAKAGE O F URINE
What is requiring to maintain urinary continence? (5)
- What is a normal voiding pattern?
- What happens to voiding patterns with age in men & women?
Requirements
1. Mobility
2. Motivation
3. Cognition
4. Manual dexterity,
5. Functionally intact urinary tract.
Normal voiding requires complex neural co-ordination to alter from urine storage in the bladder to voiding (at socially acceptable times).
Voiding Physiology Simplified
- Which nerves supply the LUT?
- Which receptors are involved?
- Outline the micturition reflex pathway (6).
Voiding mechanism (Micturition Reflex)
- Parasympathetic increases, Sympathetic decreases = Bladder contracts & Relaxes internal (involuntary) urethral sphincter
- Somatic tone decreases (pudendal nerve) = External urethral sphincter (within pelvic floor) relaxes and opens. (voluntary sphincter).
- At its simplest (seen in infants), micturition is an autonomic reflex at the spinal cord level.
Pathway
1. Stretch receptors detect filling of bladder.
2. Afferent signal to spinal cord segments S2-3.
3. Signals return to bladder via parasympathetic fibres in pelvic nerve.
4. Efferent signals excite detrusor muscle to contract.
5. Efferent signals relax internal urethral sphincter.
6. Urine involuntarily voided if not inhibited by the brain.
Voiding Physiology Simplified
- Which higher CNS centres are involved?
Complications of Urinary Incontinence
- 5 Medical?
- 7 Psychosocial?
- Causes of Transient Incontinence? = DIAPPERS?
Medical
1. UTI and Urosepsis
2. Falls
3. Fractures
4. Pressure Injuries
5. Skin and Perineal Rashes (including cellulitis, dermatitis)
Psychosocial
1. Social isolation
2. Stigmatisation
3. Embarrassment, Depression
4. SleepDeprivation
5. Sexual Dysfunction
6. Caregiver Stress,
7. Institutionalisation Risk
What are the 4 pathophysiological (non-neurogenic or neurogenic) mechanisms of established urinary incontinence? Examples of causes of each?
Established Incontinence - The result of pathophysiological (non-neurogenic or neurogenic) mechanisms.
1. Detrusor Overactivity: Cystitis, cancer, stones, urethral obstruction, MS, stroke, Alzheimer’s, Parkinson’s.
2. Detrusor Underactivity: Idiopathic, chronic outlet obstruction, autonomic neuropathy, surgical damage, disc compression, plexopathy.
3. Outlet Obstruction: Prostate (BPH, cancer), urethral stricture, spinal cord lesion with detrusor-sphincter dyssynergia.
4. Outlet Incompetence: Prostate surgery, urethral hypermobility, sphincter incompetence, radical prostatectomy with nerve damage.
List 10 Pharmaceuticals which may cause/contribute to urinary incontinence? How?
- Anticholinergics (urinary retention)
- Cholinesterase inhibitors (incontinence)
- Calcium-channel blockers (constipation - retention, fluid retention)
- ACE-inhibitors (cough – stress incontinence)
- Diuretics (diuresis)
- Sedatives (including alcohol) (functional)
- Alpha-blockers (urethral relaxation), alpha agonists (men)
- Beta-agonists (urinary retention)
- Narcotics (constipation - retention, sedation)
- Psychotropics
Outline the 5 Types of Urinary Incontinence.
What history would you take from a patient presenting with urinary incontinence?
- 3 Storage symptoms? 4 Voiding symptoms?
- What PVR is suggestive of urinary retention?
Considerations
- In frail, older people, think outside the bladder i.e., consider functional factors.
- Symptoms do not always correlate with underlying pathology.
- Urinary retention can occur because of either outflow obstruction or a non-contractile detrusor.
- A normal sized prostate on PR and PVR does not absolutely exclude obstruction.
- No agreed volume of PVR diagnostic of retention (although 200mL is often used).
- Urodynamic studies may help confirm/exclude obstruction.
What would you look for on examination in a patient presenting with urinary incontinence?
Urogynaecological Examination
- Should only be undertaken with the consent of the patient and a chaperone must always be present.
- It is generally recommended that a male doctor should have a female chaperone present (staff/family).
- Will usually be part of the work-up in a specialised Continence Clinic (not performed routinely in the ward setting).
- This examination should not be performed by someone who does not have the expertise to do so.
Basic Assessment and Workup for a patient presenting with urinary incontinence?
Other investigations as needed
1 - Ultrasound/CT (KUB)
2 - Urodynamics
- Complex patients.
- Not responding to treatment.
- Previous pelvic surgery or radiation.
- Younger patients, especially if diagnosis uncertain.
- Surgery being considered - not all cases.
3 - Cystoscopy
Outline a Summary of the treatments for Urinary Incontinence.
- Treatment Considerations?
Continence Management
Set realistic treatment goals in discussion with the patient and/or carer. In frail, older people sometimes cure is not possible. Contained Incontinence (uses pads or appliances) or Dependent Incontinence (dry with regular toileting, medications, or behaviour treatments) may be the goal.
Treatment Considerations
1. Nature of the predominant symptoms (stress versus urgency)
2. Expectations.
3. Level of patient commitment to therapy.
4. Tolerance/risk of adverse effects.
5. Financial considerations.
Urinary Incontinence
- 9 General Management Measures?
- 2 Behavioural/ Physical Interventions?
- Fluid management (How much do we recommend?)
Fluid management (How much do we recommend?)
- Frequent intake of small amounts of fluid (120 - 150mL per hour) up to 2L per day total.
- Avoid large, episodic fluid boluses.
- Law of Laplace: Bladder more likely to contract at smaller bladder volumes.
- Encourage drinking, not withholding fluid!
- Consider comorbidities e.g., heart failure.
Outline 3 Pharmaceutical options to consider for Urinary Incontinence.
Anticholinergics
- No direct comparison studies of medications used to treat UI for efficacy or adverse effects.
- Most studies have been short-term industry sponsored studies, comparing to placebo.
- Anticholinergic side effects: Dry mouth, blurred vision, urinary retention, constipation, confusion (especially in older persons). Warn patients/carers.
- Check PVR before starting therapy.
What are the Surgical Options for the management of:
- Stress Incontinence?
- Urge Incontinence?
Case-based Learning - Mrs. Drinkwater, 81-year-old female, admitted to hospital with a urinary tract infection. Long history of stress incontinence - wears pads bought from the supermarket. Incontinence usually with coughing, laughing, bending down, and walking. Seems to be getting worse. Now also experiencing some urgency in the last few months.
- What history would you take?
- What examination would you perform?
Examination Findings (In Hospital)
- Temperature 37.8 degrees C.
- Pulse rate 82 bpm.
- BP 130/85.
- SaO2 98% RA.
- Abdominal examination - mild suprapubic tenderness to palpation.
- Neurological examination unremarkable.
- Fluid status - mild peripheral oedema, chest clear. JVPNE.
- Bowels open regularly after aperients prescribed.
- Diagnosis UTI, prescribed antibiotics, discharged home with follow-up in Continence Clinic.
Mrs. Drinkwater, 81-year-old female, admitted to hospital with a urinary tract infection. Long history of stress incontinence - wears pads bought from the supermarket. Incontinence usually with coughing, laughing, bending down, and walking. Seems to be getting worse. Now also experiencing some urgency in the last few months.
- Management?
General and behavioural measures:
- Aperients for constipation.
- Dietary advice for bowels.
- Bladder training.
- Pelvic floor muscle exercises.
- Referral to continence physio and dietitian.
- Fluid advice - smaller amounts frequently up to 1.5L/day.
- Monitor fluid status with GP/ cardiologist - aim euvolaemia, avoid dehydration.
- Topical vaginal oestrogen cream (treat atrophic vaginitis) - not systemic (no efficacy and may worsen incontinence).
Management of Overflow Incontinence?
What are the 3 types of urinary catheters?
- Advantages & Disadvantages of each?
Urinary Catheterisation
- Types of catheters:
1. Indwelling (IDC)
2. Suprapubic (SPC)
3. Intermittent self-catheter (IMC)
- Short-term IDCs are commonly used in hospital for management of acute urinary retention (AUR), bladder irrigations, peri-operative setting.
- Individuals presenting with AUR may require an IDC to remain in situ for several days before attempting a trial of void (TOV). This allows the bladder to regain its tone.
- Multiple failed, appropriately timed, voiding trials warrant specialist referral.
- Most common osocomial infection worldwide?
- Role of Long-term IDCs?
- Urinary catheters - tips & tricks?
Long-term IDC
- Ideally, a long-term IDC should be avoided for incontinence management.
- An IDC is not a substitute for good nursing care.
- In rare situations, when a suprapubic catheter (SPC) is contraindicated and other continence management methods have failed, a chronic IDC may be needed.
- Safe community practice recommends that IDCs are changed every 4–6 weeks.
- Scheduled IDC changes may vary according to individual needs. However, IDC changes should never persist beyond three months.
Faecal Incontinence
- Epidemiology?
- Factors/Aetiology? (8)
Faecal Incontinence
- History?
- Examination?
- Investigations? (5)
Faecal Incontinence
- Management Strategies?
- Specialist referrals? (5)
Consider specialist referrals:
1. Gastroenterologist
2. Dietitian
3. Continence Nurse
4. Continence Physiotherapist
5. Colorectal specialist
What is the definition of Osteoporosis?
- T Score?
- Z Scores?
Osteoporosis
- Low bone mineral density (BMD) and microarchitectural deterioration of bone tissue.
- i.e., Reduced bone quantity and bone quality.
- Leads to decreased bone strength, increased bone fragility, and increased risk of fracture.
- Osteoporotic fractures usually occur from a fall from standing height (or less). Minimal trauma.
What scan can we use to measure Bone Density?
- Normal BMD Scores?
- Osteopenia?
- Osteoporosis?
Measuring Bone Density - DXA Reporting
- BMD is usually reported as a T-score (number of standard deviations (SDs) of the BMD measurement above or below that of young healthy adults of the same sex).
Epidemiology of Osteoporosis?
- Burden of Disease?
Epidemiology of Osteoporosis
- All persons lose bone with advancing age.
- Bone loss is accelerated in women after the menopause, and in older men due to declining sex hormone levels and reduced physical activity.
- Based on WHO criteria (T-score reference values):
- Aged >70 years: 13% of men and 43% of women osteoporotic, 55% of men and 49% of women osteopaenic.
- Aged 50-69 years: 3% of men,13% of women osteoporotic.
Fractures from Osteoporosis
- Epidemiology?
- Significance?
Fractures - Epidemiology
- Incidence of fracture increases with age (both sexes).
- > 70% of all fractures occur in those ≥70 years.
- Approximately 70% MTF occur in women.
- Lifetime risk of MTF in women aged >60 yrs is approximately 44%.
- Types of fracture:
- Ages 50-69: non-hip, non-vertebral most common.
- Hip fractures and vertebral fractures more common >70 years of age.
Osteoporosis - Fractures
- When should you suspect a vertebral fracture? (3)
- 9 Risk factors for Osteoporosis and Fractures?
Suspicion for Vertebral Fracture
Based on:
1. Height loss of 3cm or more.
2. Thoracic kyphosis.
3. New onset back pain suggestive of fracture.
List 13 Medical Conditions that can cause Secondary Osteoporosis?
- 5 Other medical conditions of relevance?
- List 6 Medications that can cause Secondary Osteoporosis?
Other medical history of relevance
1. Reflux oesophagitis
2. Dental/periodontal disease (date of last review)
3. Breast cancer.
4. Renal impairment
5. Atypical fractures.
Which Investigations would you consider ordering to establish a diagnosis of Osteoporosis?
- 9 Initial?
- 7 Further?
- 1 Scan? Who should get this?
- Screening? 3 Groups to consider?
Measuring Bone Density: Consensus statement
- In all Australians aged ≥70 years and in most Australians aged ≥50 years with a fragility fracture, a bone density test is recommended.
Groups to Consider
1) Postmenopausal women and men older than 50 years of age diagnosed as having at least one minimal trauma fracture (equivalent to a fall from standing height or less).
2) Postmenopausal women and men older than 50 years of age diagnosed with osteoporosis (defined as a T-score of –2.5 or less) but without evidence of a minimal trauma fracture.
3) Postmenopausal women and men greater than 50 years of age at risk of minimal trauma fracture based on history.
What is a DEXA Scan?
- How does it work?
What are the recommended investigations and treatment for:
1) a. Minimal trauma hip or vertebral
fracture (≥ 50 years of age)?
1) b. Minimal trauma fracture at any other site (non-hip, non- vertebral)?
(1) Minimal Trauma Fractures - Consensus Statement
- There is an urgency to treat patients with prevalent or recent fragility fractures.
- This includes patients with osteopaenia (the majority of patients with fragility fractures) because the risk of subsequent fractures is increased, especially in the next 12-24 months.
What are the recommended investigations and treatment for:
(2) No history of minimal trauma
fracture and aged ≥ 70 years?
(3) No history of minimal trauma
fracture but at risk (age ≥ 50)?
- Risk Factor profile?
(3) No history of minimal trauma
fracture (≥ 50 years of age).
- Consider DEXA (spine and proximal femur) based on risk factors (number and type).
- Estimate absolute fracture risk (FRAX and Garvan calculators).
- High 10-year risk of fracture Hip fracture >3%, any fracture >20% (OR T score ≤ –2.5 on DXA scan) then initiate treatment with anti-osteoporosis medication.
- Low risk of fracture, treatment not recommended.
- Address lifestyle risk factors for all.
Treatment of Osteoporosis: Calcium & Vitamin D
- Advice?
- Evidence?
- Calcium-rich foods?
Calcium and Vitamin D - Evidence of benefit
1. Beneficial effects on BMD: Calcium, vitamin D, both
2. Reduced fracture risk: Calcium and vitamin D, calcium (not vit D alone)
3. Improved muscle strength (and therefore falls prevention): Vitamin D
What are the recommended first-line anti-resorptive therapies for osteoporosis?
- How effective is anti-resorptive
therapy?
First-line anti-resorptive therapy
- 3 drugs fulfil the requirement of evidence for reduction in spine, hip and non-vertebral fractures:
1. Risedronate
2. Denosumab
3. Zoledronic acid
- Alendronate reduces vertebral and hip fractures but the evidence for non-vertebral fracture risk reduction is less robust.
- Therefore, first-line therapeutic options include:
1. Bisphosphonates (risedronate, zoledronic acid and alendronate)
2. Denosumab
What are the Biochemical markers of bone remodeling?
- Role in osteoporosis?
Bone turnover markers
- Fasting metabolic bone study (bone turnover highest early morning and food suppresses markers, especially resorption). Blood and urine.
- Non-invasive method to assess bone remodeling.
- Usefulness is debated. ? Role for monitoring compliance/effects of Rx.
- Reimbursed under Medicare for GP use in patients with osteoporosis (once per year).
Which 2 bone turnover markers suggest bone resorption?
- Which 2 suggest bone formation?
- Role in osteoporosis?
Bone turnover markers
- CTX and NTX (C and N-terminal telopeptide of type 1 collagen) – bone resorption.
- P1NP (amino-terminal pro-peptide of type 1 collagen) and ALP– bone formation.
- Most important role is measuring short-term (3-month) responses to oral bisphosphonates and anabolic drugs (Impractical to repeat BMD <2 years).
Treatment of Osteoporosis: Oral bisphosphonate
- Which has the best evidence?
- Monitoring of BMD?
- PBS funded?
- How to take the medication?
- 6 Risks/Adverse Effects?
Oral bisphosphonate
- Best evidence for risedronate (and alendronate).
- Regular review and assessment with long-term use of oral bisphosphonates is required to monitor compliance, occurrence of fractures despite treatment, and side effects.
- Enteric coated risedronate has the advantage of a lower risk of upper gastrointestinal irritation (and can and should be taken with food).
- Monitoring of BMD should be done no more often than 2-yearly (changes at one year are usually small and may not differ from the measurement error).
- PBS restricted benefit (age >70 and T score -2.5 or less; or MTF; or corticosteroid-induced osteopaenia/ osteoporosis).
Treatment for Osteoporosis: Zoledronic acid (IV)
- When to use?
- Monitoring BMD?
- Side effects?
- Who?
Treatment for Osteoporosis: Denosumab
- What is it?
- Frequency?
- Risks/Side effects?
Treatment for Osteoporosis: Other Options
- SERMs?
- Menopause hormonal treatment (MHT)?
Other Options: SERMs (Raloxifene)
- Can be considered for treatment in early/post-menopausal women.
- No evidence for prevention and reduction of non-vertebral and hip fractures.
- May be indicated in women with spinal osteoporosis and a past or family history of breast cancer.
- Reduces only vertebral fractures.
Treatment for Osteoporosis
- Choice of first-line agent?
- Bisphosphonate vs. denosumab?
- 4 Things to consider?
- 4 Advantages of oral bisphosphonates?
- 3 Contraindications to oral bisphosphonates?
Choice of first-line agent: Bisphosphonate vs. denosumab?
Advantages of oral bisphosphonates:
1. Long-term safety and fracture prevention data. - 10 years alendronate, 7 years risedronate, 6 years ZA.
2. Least expensive pharmacological option.
3. Not associated with increased risk of vertebral fracture with discontinuation of treatment or missed doses (as may occur with denosumab – fully and rapidly reverses effects on bone markers BMD upon stopping, increases fracture risk).
4. Residual fracture benefits persist even after stopping treatment. Continue for act for years after discontinuation.
Osteoporosis: Failure of First-Line Therapy
- Definition?
- Recommended treatment? (2 Agents)
Duration of treatment for Oral bisphosphonate
- Risedronate/Alendronate?
- Zoledronic acid?
- Features of high risk for future fracture risk whilst on bisphosphonate? Recommended Tx?
- Restarting bisphosphonate after a ‘drug holiday’?
Duration of treatment: Bisphosphonate in the setting of high fracture risk
High risk for further fractures:
- Osteoporotic fracture before or during Rx and/or
- T-score ≤ -3.0 in the absence of fracture.
- Continue Rx for up to 10 years (alendronate) 6 years (zoledronic acid) 7 years (risedronate) as clinical trial data show maintenance of BMD and # benefits with no significant increased risk adverse events.
Clinical conundrums in Osteoporosis
- What if BMD decreases or fracture occurs during Rx? Options?
What is the Significance of Atypical Femoral Fractures in Osteoporosis?
- What? Where?
- 3 Characteristic radiological features?
- Which meds?
- Management?
Medication-related osteonecrosis of the jaw
- Definition?
- Aetiology?
- Prevalence?
- Recommendations?
Medication-related osteonecrosis of the jaw
- Defined as an area of exposed bone in the maxillofacial region that has persisted for more than eight weeks, in a patient receiving bisphosphonates, denosumab (or anti-angiogenic therapy for cancer). No history of radiation therapy or obvious metastatic disease to the jaw.
- Aetiology uncertain.
- Related to dose and duration of treatment.
- Related to pre-existing oral disease, surgery, genetics.
- Prevalence between 1 and 10 cases per 10,000 in patients receiving oral bisphosphonate (21 cases per 10,000 after 4 years of treatment).
Stroke
- Definition?
- Components outlined in the Clinical Guidelines for Stroke Management 2017?
STROKE: Neurological injury as a result of disruption of blood supply by embolism, thrombosis, atheroma or haemorrhage.
Clinical Guidelines for Stroke Management 2017
* Pre-hospital care
* Early assessment and diagnosis
* Acute medical and surgical management
* Secondary prevention
* Rehabilitation
* Managing complications
* Discharge planning and transfer of care
* Community Participation and long-term care
Outline the Pathology & Pathophysiology of Stroke.
PATHOLOGY OF STROKE
1) Infarct
- Thrombus
- Embolus
- Lacune
2) Haemorrhage
- SAH
- Intra-parenchymal (hypertension)
- Subdural
- Extradural
Outline the symptoms of Acute ischemic stroke syndromes according to vacular territory:
- Anterior cerebral artery?
- MCA?
- PCA?
- Penetrating vessels?
- Vertebrobasliar?
- Internal carotid artery?
Outline the symptoms of the following stroke syndromes:
* TACI
* PACI
* POCI
* LACI
List 15 Acute Stroke Differentials?
Delirium
- What is it?
- List 14 Clinical prevention strategies for delirium?
Delirium prevention strategies
- It is possible to prevent delirium in at risk patients.
- Up to 30 – 40% of delirium episodes may be prevented.
- There are several strategies that could be adopted to prevent delirium (Australian, NICE, HELP guidelines).
How is Delirium diagnosed?
Diagnosing Delirium
- Delirium is a clinical diagnosis made on the basis of thorough history taking and physical examination.
- Various screening tests could be utilised to detect delirium.
- Examples of some of the screening tests include – 4AT score, short Confusion Assessment Method (short CAM), Delirium rating scale revised – 98 (DRS-R-98).
- A formal diagnosis can be made by using the DSM –IV criteria or ICD 10.
- Once delirium is diagnosed, every attempt should be made to identify the cause or precipitating factor.
List 10 Predisposing Factors & 10 Precipitating Factors/Causes of Delirium?
Outline the management of delirium.
Management of Delirium
- Delirium is most effectively managed with multidisciplinary team approach (nursing, PT, OT, dietitian, speech, SW).
- Symptomatic and supportive management include both non-pharmacological strategies and pharmacotherapy.
- Non-Pharmacological Strategies – should be utilised first in all patients with delirium and these include all the strategies outlined in the in the ‘Prevention of Delirium’ section.
- Identification, Modification and Management of predisposing and precipitating factors.
Delirium Clinical Pearls
- How long does recovery take?
- Ddxs?
- Role of physical restraints?
- When do you introduce pharmacological management options?
- Which drug for parkinsons patient?
- Recovery might be rapid, but complete resolution can take weeks (sometimes months).
- Can be associated with an irreversible decline in physical or cognitive function (RACF placement, increased mortality).
- Consider the 3D’s (dementia, depression) in DDx.
- Avoid physical restraint – aggravates agitation, leading to injuries and falls.
- Non-drug measures should be sufficient for occasional, temporary agitation which does not compromise the care of self or others.
- Main approach is nursing/carer based.
- Drugs only if non-drug failed or insufficient.
- Risk of harm to self or others.
- Antipsychotics and BZD can worsen delirium.
What is the effect of dehydration on delirium?
- How much fluid should you give them?
- Inadequate hydration can cause or worsen and prolong delirium.
- Associated with increased morbidity and mortality among older people.
- Thirst response to fluid depletion/inadequacy is altered in older persons. By the time they feel the thirst, they are dehydrated already.
- Owing to continence and mobility issues, older adults usually self limit fluid intake.
- Important to recognise the signs of dehydration.
- Classical signs of dehydration like loss of skin recoil, thirst and orthostatic hypotension are less sensitive in older persons.
- Dry oral mucosa may be a better indicator.
- Dehydrated older adults presents with atypical signs like confusion, constipation and falls.
- Fluid charts – often unreliable indicators of intake.
How can you ensure adequate hydration in the delirius elderly patient?
Role of subcut hydration?
Ensuring adequate hydration
- Educate older adults on dehydration risks
- Verbal prompting to drink in between meals
- Teach older adults not to wait to feel thirsty to drink
- Teach them to drink regularly throughout the day
- Make fluids easily accessible
- Serve fluids at a temperature the individual prefers
- Encourage water with all meals
- Promote intake of medications with fluids
- Boost the flavour of water by adding drops of lemon/ lime juice
- Limit fluid intake one to three hours before bed
- Reassure that adequate hydration will not have an effect on their
continence
Avoid or minimise caffeinated, carbonated or alcoholic drinks – increases risk of dehydration
Constipation in the Elderly
- What is normal bowel function?
- What is the definition of constipation?
- Common associations & 4 contributing factors?
- Normal bowel function varies from person to person (from 3 bowel motion/day to bowel movement once every 2-3 days).
- Constipation is a very common problem in older adults.
- It is associated with major healthcare costs and affects health related quality of life.
Constipation in the Elderly
- How might it present? (6)
- Causes - primary & secondary?
Presentations with constipation in older persons – varied.
1. Confusion
2. Overflow diarrhoea (beware)
3. Abdominal pain
4. Urinary retention
5. Nausea
6. Loss of appetite.
Constipation could be caused by primary colorectal dysfunction (slow transit constipation, dyssynergic defecation or Irritable Bowel Syndrome with predominant constipation) or secondary causes.
Constipation in the Elderly
- How would you evaluate it?
- Investigations?
Evaluation of Constipation in the Elderly
- Thorough history and physical examination to rule out secondary causes.
- Enquire about red flags (weight loss, bleeding, anaemia, family history of bowel cancer).
- Review of medications and chronic medical conditions causing constipation is essential part of evaluation.
- Abdomen and per rectal examination is a must while assessing patients with constipation.
Prevention of Constipation in the Elderly
- List 7 strategies?
Outline the management of constipation in the elderly
- List the 6 types with examples of each?
- What is the recommended daily fibre intake?
- Onset of actions of different aperients?
- Diet and Fibre – increases stool bulk causing colonic distension and promotes stool propulsion.
- Recommended daily fibre intake is 20-35gm.
- The effect of fibre on bowel movements takes several weeks.
- Bloating and flatulence are the main side effects
Constipation in the Elderly - Pearls
- Age limit for fleet enemas?
- When to repeat fleet enema dose?
- Which chart is helpful?
- What drug must you always chart aperients with?
- Good choice of laxative for immobile patients?
- Keep an accurate bowel chart (time, amount, consistency – Bristol Stool Chart)
- Management of constipation is largely empirical.
- No evidence of aperient class superiority.
- Rapid relief of constipation – suppositories, enemas, macrogol or saline laxatives to clear the rectum then ongoing management.
Outline the management of Constipation in the hospital (inpatients)?
Hypoxia & Delirium
- Goal for O2 sats?
- What ixs?
Geriatrics - Pain Management
- Impact on elderly?
- Evaluation?
Geriatrics - Pain Management
- Paracetamol?
- Nonselective NSAIDs and COX-2 inhibitors?
- Opioids?
Paracetamol
- Start paracetamol regularly in all patients with persistent pain unless contraindicated (liver failure/ insufficiency).
- Maximum daily dose should not exceed 4gm/24 hours.
Geriatrics - Pain Management
- Neuropathic pain medications?
- Table of options: Initial dose? Max dose? Special points in older patients?
Neuropathic pain medications
- Can be trialled if there is evidence of neuropathic pain. Examples include gabapentin, pregabalin (amitryptiline is in the category).
- Amitriptyline is an anticholinergic and is generally not used in older patients.
- Other antidepressants like SSRIs and SNRIs (duloxetine) can be used for treatment of neuropathic pain.
- Pregabalin and gabapentin are effective in treatment of neuropathic pain in older adults, but caution should be taken while prescribing due to risks of adverse effects – dizziness, drowsiness, fatigue etc
- Starting dose – Pregabalin – 25mg BD and gradually up titrate, Duloxetine 30-60 mg daily
Geriatrics - Pain Management
- Role of Tapentadol - IR vs. SR?
- Tramadol?
- Tapentadol has an enhanced tolerability profile (compared to other opioids) – especially suitable for treating chronic pain in older persons.
- Tapentadol has only weak effects on serotonin uptake (unlike tramadol).
- Tramadol avoided in elderly (confusion)
Approach to Falls in Hospital?
Clear evidence of headstrike
- For CT within 1 hour
- For CT within 8 hours
Which adults should receive a CT head within 1 hour of a fall with confirmed headstrike? (7)
- Within 8 hours? (4)
- Need for CT for Witnessed fall NO headstrike?
Witnessed fall, NO headstrike
- If the patient had a witnessed fall, and did NOT hit their head and do not need a CT scan of the brain:
- CT brain only required if signs of neurological impairment develop (neuro obs)
When would you consider a CT head if a patient has had an unwitnessed fall, but NO sign of a head injury?
Which patients who have had a fall need CT cervical spine within 1 hour? (7)
- Need for x-ray of extremities?
Extremities - Guided primarily by physical examination. If clinical evidence of injury, consider plain X-rays of extremities to rule out fracture. In particular, be suspicious for hip fracture and vertebral fracture.
Otherwise - Neurological observations as per falls
pathway. Re-review and investigate if clinical concern.
Helping elderly patients sleep in hospital
- How does the sleep of older people compare to younger people?
- Sleep hygiene?
- Drugs to avoid? Why?
- Role of Melatonin?
Sleep - Clinical Pearls
- Older people spend more time in lighter sleep stages (with periods of wakefulness) and nap.
- Review drugs contributing to disturbed sleep (e.g. drugs causing nocturia, nightmares, stimulants).
- Non-drug treatments are first line – use sleep hygiene and other interventions to encourage good sleeping habits.
- Sleep hygiene (avoid daytime naps, use bed for sleep or sex, avoid alcohol and stimulants like caffeine and nicotine for at least 2 hours pre-bed, get out of bed and do something if uable to sleep, get up same time each day, comfortable temp, dark and quiet environment, warm drink and snack before bed, daytime exercise) etc.
