geriatrics Flashcards
changes in ADME in older people
drug stays in body longer so can be toxic (S/E) at lower doses
- reduced first pass metabolism
- reduced hepatic metabolism
- reduced renal excretion
- increased distribution of lipophilic drugs (due to increased body fat concentraion and decreased body water concentration) –> stays in body longer
propanolol in older people
first pass metabolism declines
so more in system/ toxic at lower doses
Fatigue
Hypotension
Dizziness
hepatic metabolism decreased by
HF
smoking
ageing
digoxin in older people
reduced renal excretion so more in system/toxic at lower doses
nausea and vomiting abdominal pain Arrhythmias Yellow discoloration of vision Hyperkalemia ECG reverse kick sign
lipophilic drugs in older people
- increased distribution of lipophilic drugs
- due to increased body fat concentraion and decreased body water concentration
- diazepam
- Chlordiazepoxide
diazepam in older people
Increased distribution of lipophilic drugs due to increased body fat concentraion and decreased
Drowsy
Confused
when cutting down polypharmacy, which are often booted out (8)
- secondary prevention drugs (bisphosphonates, statins)
- antihypertensives if patient experiencing postural hypotension
- quinine (Prescribed for night leg cramps but doesn’t work)
- Tricyclics, amitriptyline, anti-constipation (bad for cognition)
- st johns wart
- weak painkillers when on stronger ones
- dual antiplatlet therapy if MI over 1y ago
- high risk of toxic effects (diazepam, propanolol, warfarin, nitrates, digoxin,…)
define fragility fracture
fall from standing height or less that results in broken bone
things that improve orthogeriatric outcomes
Prompt orthogeriatric assessment -- 72h Prompt surgery -- 36h Pre-surgical cognitive testing Prompt mobilisation after surgery -- day on / after surgery Not delirious in post-surgery assessment Returned to original residence by 120 days Nutrition assessment Fracture prevention assessment
frailty =
Related to age but not essential with ageing
Multiple body systems
Less ability to withstand an insult
- More at risk of adverse outcomes - hospital admission, reduced mobility, loss of independance, reduced ADL function, death
frailty prevention
Good nutrition
Physical activity
Avoid social isolation
Limited alcohol intake
frailty assessment
Clinical frailty scale (CFS) aka Rockwood
- 1-9
- quick and easy
- not valid for measuring improvement after acute illness or if patient younger than 65
Fried criteria (phenotype) 3 or more of: - Unintentional weight loss - Self-reported exhaustion - Weakness - grip strength - Slow walking speed - Low physical activity 2 = “pre-frail”
e-FI electronic frailty index
36 possible deficits
- Comorbidities - DM, HTN, Renal disease
- Polypharmacy / multimorbidity
- Sensory impairment
- Self-reported symptoms (Dizziness, Sleep disturbance)
- Social factors (Social isolation, Living alone)
presence/ absence of deficits as a proportion of the 36
Walking speed
Grip strength
Up and go time
- Time to stand up walk 6m (or 3m, turn and back) and sit again
- Should be 10s or less
PRISMA 7
- 7 item questionnaire
- 3 or more is :/
Groningen questionnaire
- 15 items
- 4 or more is :/
first line bisphosphonate
alendronic acid
difficulty with taking alendronic acid
alternative
need to take 1st thing in morning and remain upright for 30 mins
this is hard when cognitive impairment is involved
zolendronic acid IV - sometimes just one dose for a few months-years
end of life indicators
Weight loss Recurrent unplanned admissions Delirium Frailty rising Frailty plus dementia Comorbidities Recurrent and persistent infections Not responding to medication
when is there increased nutrition requirements
injury
sepsis
consequences of malnutrition
Weakened immune system - Prone to infection Muscle wasting - Arms and legs especially visible - Falls, mobility problems - Increased chest infections Impaired wound healing - Longer hospital stay Micronutrient deficiency
MUST tool =
malnutrition universal screening tool
- BMI (weight, height)
- weight loss
- acute disease effect (Yes/no) = Patient nil by mouth or likely not to eat at all for 5 days or more (past or future)
malnutrition treatment
- food - snacks, nourishing drinks, food fortification
- oral nutrional supplements (ONS) - improve micro/macro intake: juice/ milkshake/ soup/ powder/ semisolid
- enteral feeding
- parentral feeding
enteral feeding types
straight into gut:
NG nasogastric tube
nasojejunal tube
PEG tube (percutaneous endoscopic gastrostomy )
PEJ percutaneous endoscopic jejunostomy
parental feeding =
fed via IV- PICC / central line
when gut is inaccessible or unable to absorb sufficiently
TPN =
TPN = total parenteral nutrition
IV feeding via central/PICC line
parental feeding pros and cons
Advantages - Meet nutritional requirements - Easily tolerated Disadvantages - More costly - Risk of line infection ---- Unlikely but serious risk if occurs - More invasive - Gut atrophy - villi flatten ---Reduced absorption when go back to gut feeding
indications for parental feeding
Inadequate absorption -- Short - bowel syndrome -- Due to surgery Gastrointestinal fistulae Bowel obstruction Prolonged bowel rest -- Severe IBS sometimes want to rest the gut Severe malnutrition, significant weight loss and/or hypoproteinemia when enteral feeding isnt an option
enteral feeding pros and cons
Advantages - Preserves gut mucosa and integrity - Improves nutritional status - Inexpensive (compared to parenteral nutrition) Disadvantages - Tolerance issues --- Nausea --- Satiety --- Bowels --- But may be something else so need to check first eg Medication esp if changed recently - Discomfort of tube placement - Quality of life, dignity, confidence (aesthetic displeasing appearance for patients)
NG tube
- how is it inserted
- check its position how
- maximum duration of tube presence
inserted on ward - slide tube in with lube, swallowing helps
Check it is in the right place using aspirate pH (gold standard) – <5.5
X Ray confirmation is second line position check
<30days (consider PEG after)
nasojejunal feeding
- how is it inserted
- maximum duration of tube presence
Needs to X Ray guided, not on ward
Unable to use aspirate to check if it is in the right place
<60days
PEG tube indications
- Consider if NG tube in for 30days
- Dysphagia (stroke, head injury, neck surgery) Not improving
- Cystic fibrosis – High nutritional requirements
- Oral intake inadequate and this is likely to be the case long term
PEJ indications
Not tolerating PEG feeding
Delayed gastric emptying
Upper GI/ pancreatic surgery (bypass pancreas)
High risk of aspiration
Severe acute pancreatitis (bypass pancreas)
refeeding syndrome
- what is this
- risks
- actions
When malnutrition/ starved patient when reintroducing nutrition - Due to energy stores shift from fat metabolism to carbohydrate metabolism. This promotes insulin secretion and therefore cellular uptake of potassium, phosphate and magnesium
- electrolytes drop
- Fluid retention
- Cardiac arrhythmias
- Respiratory insufficiency
- Death (Rarely)
- refeeding bloods monitoring to check for electrolytes
- Slow introduction of nutrition - esp carbs
- in high risk patients : IV (if unable to take tablets) pabrinex or thiamine + vitamin B co-strong PRIOR to feeding and 10 days into feeding
