Frailty and Death

Question 1

How does frailty affect someones ability to deal with external stressors e.g. minor illness or injury?

Answer 1

The frailer a person is, the less likely they are to return to their basline level of function

Question 2

What is one of the main side effects of anticholinergic drugs when used in the elderly? (e.g. ACE inhibitors, Furosemide, Oxybutynin, Digoxin, Apixiban)

Answer 2

Urinary retention

Question 3

What causal pathways lead to ineffective and inefficient care and what is the consequence of this?

Answer 3

Question 4

What assessment tool is used to help create a care plan for elderly patients?

Answer 4

Comprehensive Geriatric Assessment

Question 5

What factors are assessed in the comprehensive geriatric assessment?

Answer 5

1. Environment
2. Medical
3. Psychological/cognitive
4. Functional ability
5. Social networks/ support

Question 6

List some of the differential diagnosis of why an elderly person may present with delirium

Answer 6

• Aspiration pneumonia
• Anticholinergics (Burden score of 6)
• Urinary retention
• Constipation
• Acute on chronic kidney injury
• Underlying vascular dementia
• Polypharmacy
• Anaemia on NSAIDs & DOAC
• Swallowing difficulties
• Approaching end of life

Question 7

How would manage a patient with mild frailty?

Answer 7

Treat as usual

Address reversible issues: nutrition, social prescribing

Question 8

How would you manage a patient with moderate frailty?

Answer 8

Actively seek out and manage geriatric syndromes e.g. falls, congnitive impairment, continence, polypharmacy , perform comprehensive geriatric assessment

Question 9

How would you manage severe frailty?

Answer 9

• Think about supportive care vs cure
• Advance care planning
• Recognise that enhanced supportive care is an effective intervention

Question 10

What are some of the challenges to achieving a good death?

Answer 10

• Truthfullness with patients
• Enabiling informed consent
• Allowing time to prepare
• Avoiding isolation
• Overcoming a wall of silence
• Maintaining hope

Question 11

What are the psychological stages of dying? (Kubler-Ross Grief curve)

Answer 11

1. Anger
2. Denial
3. Bargaining
4. Depression
5. Acceptance (or Resignation)

Question 12

What factors contribute to a ‘good death’?

Answer 12

• Avoiding medicalisation (thus prolonging dying process)
• Avoiding situation of being medically captive
• Making an agreed care plan to avoid ‘managed states’
• Ability to die one’s own death
• Adequate symptom control

Question 13

What should doctors consider about the ‘informal carer’?

Answer 13

• Often unintentioanlly neglected by professional carers
• A lot of support and input required
• Are there any opportunities for respite care?
• Grief before and after death
• Make sure they don’t feel guilty of having ‘failed’ their loved one

Question 14

What are the key principles of a good death? (12)

Answer 14

• To be warned when death is coming and learn what can be expected
• To be able to retain control over what happens
• To be afforder dignity and privacy
• To have control over pain relief and other symptom control
• To have a choice over where death occurs
• To have access to information and expertise of any kind necessary
• To have access to any spiritual or emotional need
• To have access to hospice care
• To have control over who is present in the end
• To be able to issue advanced directives to ensure their wishes are respected
• To have time to say goodbye
• To be able to leave when it’s a good time to go, and not have life prolonged pointlessly