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MC > The Elderly Patient > Flashcards

The Elderly Patient Flashcards

1
Q

The ageing ________ are the fastest growing
section of the Australian population. The number of
‘old-old’ _______ is increasing at an even faster
rate.1

A

(over 65 years)

over 85 years

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2
Q

Life expectancy has risen to _____ years for women

and _____ for men

A
  1. 2

79. 7

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3
Q

The over-65s in 2001 made up ______of the Australian

population (13.4% in the US)

A

12.7%

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4
Q

The over-65s use twice the number of health services
per head of population. They account for____ of all
hospital costs and 75% of all _______ costs

A

25%

nursing home

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5
Q

Ageing is characterised by the following:

  • decrease in______
  • reduction in the _______ of organs
  • reduced capacity to adapt to______
  • increased vulnerability to disease
  • increased probability of death
A

metabolic mass

functional capacity

stress

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6
Q

Degenerative cardiovascular disease emerges with ageing
according to the following approximate guidelines

40 Obesity
50 Diabetes
55\_\_\_\_\_\_\_
65 Myocardial infarction
70 \_\_\_\_\_\_\_\_\_
75 Heart failure
80 \_\_\_\_\_\_\_\_\_\_\_\_
A

Ischaemic heart disease

Cardiac arrhythmias

Cerebrovascular accident

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7
Q

What is the classic triad of aging

A

confusion, falls, incontinence

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8
Q

The classic triad often represents:

A

infection

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9
Q

A clinically signifi cant feature in some elderly patients
is the raising of the pain threshold and changes in
homeostatic mechanisms, such as _______

Consequently, these patients may have an abnormal
response to diseases such as appendicitis, pyelonephritis,
internal abscess, pneumonia and septicaemia

A

temperature control.

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10
Q

One of the best ways to generate a good relationship with the aged is through

A

home visits

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11
Q

Home visits can be considered in three categories:

1 an_______ visit (especially to a new patient)
2 a patient-initiated but routine request for a ‘check-up
and tablets’
3 the_______—usually 2 to 4 weeks

A

‘unexpected’

regular call

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12
Q

Forbes points out that at least _________elderly
people feel lonely. It is more likely to affect the_____
widows and widowers, and those affected by disability.

A

one in three

‘old-old’,

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13
Q

Possible signs of loneliness include:

  1. 2.
  3. body language with a ‘defeated’ demeanour
  4. prolongation of visit including holding on to one’s hand
A
  1. verbal outpouring
  2. drab clothing
  3. dependence on television
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14
Q

Doctor behaviour that can irritate
and confuse elderly patients:

• having a consulting room with slippery steps, poor
lighting and inadequate handrails
• non-attention to______ by reception staff
• keeping them waiting
• having________in the waiting room and surgery
• being overfamiliar, with addresses such as ‘Pop’ or fi rst
names for elderly females

A

simple courtesies

low soft chairs

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15
Q

Doctor behaviour that can irritate
and confuse elderly patients:

• shouting at them on the assumption that they are_____
• appearing _____and keen to get the consultation over
quickly
• forgetting their ________ and
concentrating only on their physical problems (i.e. not
treating the whole person)
• forgetting that they have several things wrong with
them and using a different ______ from theirs

A

deaf
rushed

psychosocial problems

priority list

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16
Q

Doctor behaviour that can irritate
and confuse elderly patients:

being unaware that they may have seen other
practitioners or may be _________
• failing to ask patients to give their understanding of
what is wrong
• omitting to give printed _______
about their problems and medications

A

taking additional medication

patient education handouts

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17
Q

Doctor behaviour that can irritate
and confuse elderly patients:

omitting to explain __________
• treating them as though they would have little
comprehension of their health and treatment
• failing to respect their privacy, such as__________
• failing to provide appropriate advice on various social
services such as ________ and other support
groups

A

how the medication will work

not knocking
before entering the examination room

meals on wheels

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18
Q

Assessment of the elderly patient

At all times concentrate on a general
assessment of the patients’ _________ by
evaluating mental status, comprehension, hearing,
vision, mood and speech.

A

ability to communicate

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19
Q

Physical examination

The elderly patient expects to
be examined adequately (especially having ___________measured) but requires appropriate dignity

A

blood pressure

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20
Q

Physical examination

Practice nurse
• Prepares for \_\_\_\_\_\_\_
• Helps with questionnaire
• Records \_\_\_\_\_\_
• Takes temperature, pulse and respiration
• Checks audiometry (if hearing problem)
• Checks \_\_\_\_\_\_\_\_\_ (if appropriate)
• Prepares cervical smear tray for female patient (if
relevant)
A

examination

weight and height

ocular tension

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21
Q

_______ for assessment of the

non-coping elderly patient

A

‘Rules of 7’

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22
Q

‘Rules of 7’ in elderly assessment

1 Mental state: _________ Bereavement, incl. pets, Elderly abuse/bullying
2 Eyes: Visual acuity,________
3 Ears: Deafness, e.g. wax Tinnitus
4. Mouth: _____, _________, Malnutrition

A
  1. Confusion/dementia Depression
  2. Cataracts/glaucoma
  3. Dentition Xerostomia
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23
Q

‘Rules of 7’ in elderly assessment

5 Medication: _________
6 Bladder and bowels: ____________

A

Polypharmacy Adverse reactions

Incontinence Retention Urinary infection

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24
Q

‘Rules of 7’ in elderly assessment

Locomotion: Gait—\_\_\_\_\_\_\_\_ movement disorder, esp. \_\_\_\_\_\_\_
Arthritis—hips/knees
Back/sciatica
Feet—\_\_\_\_\_\_\_\_
Circulation
Leg ulcers
A

antalgic;

Parkinson disease

nails; neuropathy

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25
Q

The quick 10-step cognitive impairment test

  1. 2.
  2. 4.
A

1 When were you born?
2 What year is it?
3 What month is it?
4 What is the date today?

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26
Q

The quick 10-step cognitive impairment test

  2. 7.
    8.
    9.
    10.
A

5 What is your telephone number? (or if no
telephone) What is your street address?
6 What time is it (to nearest hour)?
7 Who is the Prime Minister of Australia?
8 What year did World War II end?
9 Count backwards from 20 to 1.
10 Repeat the memory test I gave you

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27
Q

The quick 10-step cognitive impairment test

_____ not signifi cant
_____ probably signifi cant
______ signifi cant

Scoring: questions 1 to 8: correct—0, incorrect—2;
questions 9 and 10: correct—0, 1 error—2, >1 error—4

A

0–8

9–12

13–24

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28
Q

_________
This relatively simple test provides a ready qualitative
screening test to differentiate normal elderly from patients
with cognitive impairment, particularly dementia

A

The clock-face drawing test

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29
Q

Scoring system for CDT

Scoring system
• _____________—3 points
•______________—2 points
• All correct numbers are included—2 points
• Clock hands are placed in the correct position—2 points

A

Numbers are in the correct position

A closed circle is drawn

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30
Q

The clinical features of early dementia include:
• poor _______ memory
• impaired acquisition of new information
• mild _____ (cannot remember names)
• ________ (e.g. withdrawn, irritable)
• minimal visuospatial impairment (e.g. tripping easily)
• inability to perform ___________

A

recent

anomia

personality change

sequential tasks

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31
Q

Even apparently minor problems—such
as the onset of deafness (e.g. wax in ears), visual
deterioration (e.g. cataracts), _______ poor
_______ and diet, urinary tract intercurrent
infection, _______ and ________—can precipitate
abnormal behaviour.

A

diuretic therapy,

mastication

boredom and anxiety

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32
Q

Mnemonic for dementia

D drugs and alcohol \_\_\_\_\_
E ears, eyes
M \_\_\_\_\_, e.g. hyponatraemia, diabetes mellitus, hypothyroidism
E \_\_\_\_\_\_\_\_\_\_
N \_\_\_\_\_\_\_\_
T tumours, trauma
I infection
A \_\_\_\_\_\_\_\_
A

depression

metabolic

emotional problems (e.g. loneliness)

nutrition: diet (e.g. vitamin B group defi ciency, teeth
problems)

arteriovascular disease → cerebral insuffi ciency

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33
Q

It is important to keep in mind the possibility of abuse

of the elderly, especially where there is ______

A

a family history

of abuse of members

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34
Q

Over one million elderly people are
estimated to be the victims of physical or psychological
abuse each year in the US.3 We should keep in mind
the occasional possibility of______

A

Munchausen syndrome

by proxy.

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35
Q

The main differential diagnosis of dementia is
depression, especially major depression, which is termed
________

A

pseudodementia

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36
Q

The _______ is one way in which
it may be possible to distinguish between depression
and dementia

A

mode of onset

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37
Q

Those with dementia ________ while

those with depression ___________ and readily give up tasks

A

have no insight

have no insigh

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38
Q

In response to cognitive testing, the typical response
of the depressed patient is _________, while making
an attempt with a near-miss typifi es the patient with
dementia

A

‘don’t know’

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39
Q

It is vital to detect depression in the elderly as they

are prone to_____

A

suicide

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40
Q

The incidence of dementia increases with age, affecting

about 1 person in 10 over _______ and 1 in 5 over ____

A

65 years

80 years.

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41
Q

dementia or pseudo?

Worse in evening or night

Orientation is reasonable

A

dementia

pseudo

42
Q

In _____ the earliest
manifestations are personality change and alteration
of behaviour, including social dysfunction

A

frontal dementias

43
Q

______ is characterised by any two of visual
hallucinations, spontaneous motor Parkinsonism and
fl uctuations in the mental state

A

Dementia

with Lewy bodies

44
Q

In patients with dementia, _____ judgment, verbal fl uency and the ability to ________ also become impaired.

A

Abstract thinking,

perform complex tasks

45
Q

The many guises of dementia can be considered in
terms of four major symptom groups:

  1. _______: due to loss of cognitive abilities
  2. ______: based on personality change,
  3. __________based on disturbed mood
    and personal distress
  4. ________—causing distress and
    disturbance to others
A

Defi cit presentations—

Unsociable presentations—

Dysphoric presentations—

Disruptive presentations

46
Q

In patients with dementia, Driving is a problem, especially as many are reluctant to give up their licence. Those with ______ are more likely to cause road accident

A

mild dementia

47
Q

If uncertainties arise in drivign or a patient is recalcitrant,
refer to the _________

A

local Road Traffi c Authority

48
Q 
Demented patients are vulnerable to
superimposed delirium, which is often due to:
1.
2.
3. 
4.
A
  • urinary tract infection
  • other febrile illness
  • prescribed medication
  • drug withdrawal
49
Q

The best

option for PD and AD appears to be the administration of:

A
  • levodopa to maximum dose

* quetiapine at night

50
Q

The cholinesterase
inhibitors _________, ____, ________
appear to delay progression of dementia to a modest
extent only.

A

donepezil, galantamine, and rivastigmine

51
Q

Available drugs for Alzheimer disease
Cholinesterase inhibitors

  • donepezil (Aricept) ______
  • galantamine (Reminyl) prolonged release ______
  • rivastigmine (Exelon)

rivastigmine (Exelon) 4.6 mg transdermal daily for
4 weeks, then______

A

5 mg (o) nocte for 4 weeks, increase to 10 mg nocte as tolerated

8 mg (o) daily for 4 weeks, increase to 16 mg daily

1.5 mg (o) bd for 2 weeks,
increase gradually up to 6 mg bd

9.2 mg daily

52
Q

Aspartate (NMDA) antagonist

• memantine (Ebixa) _______

A 
5 mg (o) mane for 1 week →
5 mg bd week two → 10 mg bd from week 4
53
Q

True about RCTs on donepezil and riva

  • only ______ improvement overall
  • greatest improvement with _____ doses
A

modest

higher

54
Q

True about RCTs on donepezil and riva:

  1. higher doses less well tolerated
  2. long-term effi cacy ______
  3. clinical effectiveness in ______ has not been
    demonstrated
A

unknown

severe disease

55
Q

In AD Tx,

the evidence shows
that ________ must be treated with rivastigmine
6–12 mg/day for 6 months for one patient to display
clinically meaningful improvement

A

13 patients

56
Q

Tx of Psychotic Sx of AD
1.
2.
3.

A 
olanzapine 2.5–10 mg (o) daily
or
risperidone 0.5–2 mg (o) daily
or
haloperidol 0.5 mg (o) nocte up to 2 mg bd
57
Q

To control symptoms of anxiety and agitation use:

______

A

oxazepam 15 mg (o) one to four times daily

58
Q

benzodiazepines should be used only for short
periods________ as they tend to exacerbate
cognitive impairment in dementia

A

(maximum 2 weeks)

59
Q

In AD, Defi ciencies of ______, ________, ______should be treated.

A

folate,

vitamin B12 and vitamin D

60
Q

This ‘popular’ term is also referred to as ‘age-related

memory loss’ or ‘mild cognitive impairment’ of ageing

A

Benign senescent forgetfulness

61
Q

Features of Benign senescent forgetfulness

  2. 3.
A
  • short-term forgetfulness
  • inability to fi nd the right word
  • embarrassment about shortcomings
62
Q

Features of Benign senescent forgetfulness
4.
5.
6

A
  • feeling dithery
  • inability to fi nd items stored away
  • forgetting to pay accounts
63
Q

The risk factors for late life

suicide are:

A
  • male
  • single
  • recent bereavement
  • social isolation
  • recent relocation
  • poor pain control
  • feeling helpless/hopeless
  • anhedonia
  • indicating a wish to die
  • recent alcohol abuse
64
Q

________ is that condition where the symptoms
and signs of paranoid psychosis appear for the fi rst
time in the elderly

A

Paraphrenia

65
Q

In patients with Paraphrenia, it is usually an elderly
female, presents with ______, such as
a feeling of being watched or persecuted and even
_______

A

paranoid delusions

hallucinations.

66
Q

Tx of paraphrenia

A

Treatment
is with an anti-psychotic agent e.g. risperidone or
olanzapine.

67
Q

Falls in the elderly are a major problem as _____of people
over the age of 65 experience at least one fall per year,
with 1 in 4 of these having ______

A

30%

signifi cant injury

68
Q

The ________ test: a brief test of

postural competence

A

‘get up and go’

69
Q

Steps for get up and go:

1 Get up from chair without ____
2 Observe normal gait and ______
3 Carry out the _________ (slight push with eyes
closed).
4 Observe _______ (heel toe, straight line).

A

use of arms

360° turn.

Romberg test

tandem walking

70
Q

Ageing is associated with increased rates of adverse
drug reactions.1 The rate of adverse drug reactions for a
single medication rises from about ______ at age 20 years to about ______at age 70 years.

A

6%

20%

71
Q

For fewer than six medications taken concurrently, the

rate of adverse drug reactions is about______.

A

6%

72
Q

For more than
six medications taken concurrently, the rate of adverse
drug reactions jumps to _____

A

20%.

73
Q

Approximately ______of
elderly patients admitted to hospital are suffering adverse
drug reactions.

A

15%

74
Q

Most adverse drug reactions are ______ rather than type B (idiosyncratic).

A

type A (dose related)

75
Q

The fi ve mechanisms of adverse drug reactions in

the elderly are

A
  1. Drug–drug interaction
  2. Drug–disease interaction
  3. Age-related changes leading to increases in drug plasma concentration
  4. Age-related changes leading to increased drug sensitivity.
  5. Patient error
76
Q

The fi ve mechanisms of adverse drug reactions in
the elderly

__________ For example, beta-blockers given
concomitantly with digoxin increases the risk of heart
block and bradycardia

A

Drug–drug interaction.

77
Q

______ For example, in the presence
of kidney impairment, tetracyclines carry an increased
risk of kidney deterioration

A

Drug–disease interaction.

78
Q

______. Decreased kidney excretion can extend
the half-life of medication, leading to accumulation and
toxicity

A

Age-related changes leading to increases in drug plasma

concentration

79
Q

____________
For example, there is some suggestion that the
pharmacological response to warfarin, narcotics and
benzodiazepines is increased in the elderly

A

Age-related changes leading to increased drug sensitivity.

80
Q

______Multiple medications can lead to this. The incidence and prevalence of dementia also
increases with age. Other problems include failing
eyesight and reduced manual dexterity.

A

Patient error.

81
Q 
In a study on adverse drug reaction in elderly
patients the drugs most frequently causing admission
to hospital were:
1.
2.
3. 
4. 
5
A
  • digoxin
  • diuretics
  • antihypertensives (including beta-blockers)
  • psychotropics and hypnotics
  • analgesics and NSAIDs
82
Q

The same study showed that drugs regularly

prescribed without revision were:

A
  • barbiturates
  • benzodiazepines
  • antidepressants
  • antihypertensives
  • beta-blockers
  • digoxin
  • diuretics
83
Q

The elderly may need much lower doses of
______ and ________than younger patients to
produce the same effect, thus rendering them more
susceptible to adverse effects and toxicity

A

anxiolytics and hypnotics

84
Q

The elderly

are especially liable to accumulate the _____

A

longer-acting

benzodiazepines

85
Q

In particular, any drug or combination of drugs with
anticholinergic properties (e.g. tricyclic antidepressants,
anti-Parkinsonian agents, antihistamines, phenothiazines
and some cold remedies) can precipitate a ____

A

central

anticholinergic syndrome.

86
Q

Both ___ and ______
have been shown to produce a greater fall in blood
pressure in elderly compared with younger subjects,
presumably related also to a reduced homeostatic
response

A

ACE inhibitors and calcium-channel blockers

87
Q

SE in the elderly

Confusion, falls,
psychomotor impairment

A

BZD

88
Q

SE in the elderly

Confusion, falls, asthma,
insomnia

A

β-blockers

89
Q

SE in the elderly

Confusion

A

Cimetidine

90
Q

SE in the elderly

Nausea, confusion

A

Digoxin

91
Q

SE in the elderly

Incontinence, falls,
hyponatraemia,
hypokalaemia

A

Diuretics

92
Q

SE in the elderly

Confusion, falls,
dystonia, hallucinations,
agitation, postural
hypotension

A

Levodopa

93
Q

Confusion, extrapyramidal

symptoms

A

Metoclop

94
Q

Confusion, postural
hypotension, falls,
constipation

A

Phenothiazines

95
Q

SE in the elderly

Confusion, falls, ataxia,
Parkinsonism, urinary
problems

A

Phenytoin

96
Q

SE in the elderly

Postural hypotension,
incontinence

A

Prazosin

97
Q

SE in the elderly

Nausea, agitation,
insomnia

A

SSRI antidepressants

98
Q

SE in the elderly

Confusion, falls,
postural hypotension,
constipation, urinary
problems, eye problems

A

Tricyclic antidepressants

99
Q

SE in the elderly

Constipation

A

Verapamil

100
Q

The starting dose of a drug in the aged should be
at the_____of recommended ranges. Dosage
increments should be gradual and reviewed regularly.

A

lower end

MC (90 decks)

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