Aged Care Flashcards
Risk factors/predisposing factors for delirium
- Elderly/frail patients
- Pre-existing cognitive defects (dementia, past brain trauma, PD, stroke, tumour, MS)
- Meds: Polypharmacy or rapid escalation of opiod dose
- Sensory impairment/deprivation and immobility
- Multiple chronic medical conditions (cancer, organ failure, recurrent infx, neuropathic pain)
- Previous delirium
- Dehydration, malnutrition and sleep deprivation
Precipitating factors for developing delirium
- MEDS (anticholinergic and polypharmacy! change in meds)
- Intoxication, substance withdrawal (alch, benzos)
- Severe/multiple medical problems
(INFX/SEPSIS, fever/hypothermia, metabolic encephalopathies, DEHYDRATION/poor nutrition, ELECTROLYTE imbalance, organ failure, hypoxia), hypotension, constipation, retention, hyper/hypoglycaemia, cancer, FRACTURES, AMI - SURGERY and anaesthetics (esp emerg, lengthy and ortho procedures)
- Acute brain pathology (STROKE, abi, trauma)
- Environment (sleep, urinary catheter, pain and discomfort, unfamiliar environment, immobility, restraints, absence of sensory aids)
DDX disturbed behaviour
Delirium
Dementia
Depression or mania (mood disorders w psychotic SX)
Primary psychotic disorders (Schizophrenia/delusional disorder, schizoaffective disorder, schizophreniform psychosis, brief psychotic disorders)
Drug-induced (intoxication or withdrawal)
Organic psychoses
Diagnosis of delirium
Confusion assessment method (CAM)
Presence of both:
- Acute onset and fluctuating course
- Inattention
Plus one of the following:
- Disorganised thinking (speech, memory, hallucinations, delusions etc)
- Altered conscious state
Diagnosis of dementia
Other screening tests
Via MMSE
Score <24 indicates cognitive impairment
Other:
- MoCA
- RUDAS
- ACE-R
- Clock-drawing test
- Neuropsych assessment
What are the limitations of the MMSE
Doesn’t test executive function
Depends on patient’s education, culture, language, sensory abilities etc
DSM5 Criteria for dementia
A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains*:
- Learning and memory
- Language
- Executive function
- Complex attention
- Perceptual-motor
- Social cognition
B. The cognitive deficits interfere with independence in everyday activities.
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. The cognitive deficits are not better explained by another mental disorder (eg, major depressive disorder, schizophrenia)
Auditory Agnosia
Inability to understand/comprehend speech despite intact hearing, speech production and reading abilities
Apraxia
Inability to coordinate muscles to produce speech due to loss of motor cortex function
Causes of dementia in order of occurrence
- Alzheimer’s disease (70%)
- Vascular dementia (15%)
- Fronto-temporal dementia (10%)
- Lewy-body/Parkinson’s dementia
Diagnosing geriatric depression
+ SX
Geriatric depression survey (GDS)
SX
- decr mood and anhedonia
- insomnia
- decr appetite
- psychomotor sx
- mood congruent delusions/hallucinations
- self-harm
- COGNITIVE/MEM IMPAIRMENT (subjective = pseudodementia)
- SOMATIC complaints and HYPOCHONDRIASIS
What is fronto-temporal dementia characterised by?
Problems w
- social behaviour
- impulse control (disinhibition, suddenly have an uncontrollable sweet tooth)
- personality
- inappropriate behaviour
- planning and sequencing
Fronto-temporal dementia:
Ave age onset
Pace of onset
Progression/Prognosis
Onset <70yo
Quick onset over 6mo
Quick progression/decline (~7 years)
Baseline inx for dementia
Imaging-CTB Bloods - FBE CRP UEC CMP LFT TFT B12, folate, thiamine
Urine dipstick and MSU and ACR
Baseline inx for delirium
CXR
MSU
Bloods: FBE, CRP UEC, CMP (Ca) LFT PO4 BSL saO2
Drugs more likely to cause delirim
Steroids
Digoxins
Anticholinergics (TCAs, oxybutinin, anti PD, antihistamines)
Benzos
Opiods
How to manage sleep in delirious patients
□ Non-pharmacological techniques (re-orientation and gentle nursing etc)
□ Soft low-level light
□ Medications for those who do not settle w gentle/conservative measures
® Low-dose Quietapine can help them sleep (Only available in tablet form)
® Olanzapine can be given as SC injection or wafer which can be advantageous
Simple management measures to help with delirium whilst waiting for inx. results
§ Withdrawal: Nicotine patch
§ Treat constipation - laxatives, fibre, fluids
§ Optimise diabetic control
§ Review medications - reduce opiods if pain is under control
§ Ensure adequate sleep
§ Ensure they have hearing aids in
When conservative mx fails:
§ Medication (quetiapine, olazapine, haloperidol)
Types of delirium
Hyperactive
Hypoactive
Mixed types (fluctuates between hypo and hyperactive states)
What patients are at risk of hypercalcaemia and what does this predispose them to?
- SCC of lung, breast, renal cell, prostate, head and neck
- Bony mets
Risk of developing delirium
Managing delirium in terminal phase - terminal restlessness
Bladder scan to check full bladder/bowel (IDC if necessary)
Control pain/consider reducing opiod dose or opiod rotation if well-controlled
Sedation
Sedative agents used in terminal restlessness
BENZOS 1st line
LEVOMEPROMAZINE is 2nd line
PHENOBARBITONE if all else fails
What benzos are used for terminal restlessness?
Midazolam first line, or clonazepam (both available as SC injections or SC continuous infusions via syringe driver)
Can use lorazepam as S/L form
RFs for stress incontinence
Women (pregnancy)
Men who have had prostate/rectal surgery
Obesity
Chronic sneezing, coughing, running, lifting
Stress incontinence picture:
- leakages
- bladder diary
Small vol leaks with rise in IAP
Normal bladder diary
Management stress incontinence
Pelvic floor exercises and assessment of technique by continence physio (trial for 3 months)
Topical estrogen if post-menopausal (cream, tablet, pessary)
Surgery (trans-vaginal tape)
Overactive bladder - causes
Idiopathic is most common cause
MS (disrupts message to inhibit reflex)
Post-stroke
PD
SX of overactive bladder
Freq
Urgency with triggers - Water, key in door, laugh, cold
Nocturia
sensation of large vol leaks
Bladder diary with overactive bladder
Frequency
Small volume voids
Nocturia
Management of overactive bladder
Bladder retraining (trial 6weeks-8mo)
- Deferment
Or Timed toileting
Pelvic floor exercises
Avoid/reduce caffeine and alcohol Increase fluids (maintain ~1500ml)
Use pads (confidence in social situations)
Medication if conservative MX fails
- Oxybutynin (anticholinergic) - Beta3 agonist - Botulinum toxin
Side effects of anticholinergics
Dry mouth
Retention
Components of a geriatric psych assessment
- Physical
- Sensory impairments and aids
- Frailty: mobility, comorbidities and gait/abnormal movements - Mental
- Psychiatric and psychological
- Cognitive - Social
- Family, friends, supports
- Living condition
- Finances
- Hobbies, religiosity
- Culture and language
- Stigma - Risk assessment
- Assess competence (appoint an enduring power of attorney)
- Driving
- Finances and legal matters
- Lifestyle and accom
- Medical tx
Domains of cognition
Attention Visuospatial Language Memory Executive function
Assessment of attention
Serial 7s
World backwards
Days of week or months of year backwards
Orientation to TPP
Assessment of visuospatial
Drawing reproduction
Clock drawing
Memory assessment
Recall 3 objects
Items starting with P and/or animals in 1min
Produce drawing after delay
Exec function assessment
Proverbs (no ifs, ands or buts)
3 step command (motor sequencing)
Categorical fluency (naming animals)
Clock drawing
Language
Reading and comprehension (close your eyes)
Write a sentence
Word finding
Components of a cognitive assessment
Hx - req collateral history
- what is their baseline, age and education?
- time course
- rule out medical causes for decr cognition and delirium
Functional assessment
- PADLs, DADLs, IADLs
- Mobility
- Frailty
- Supports
- Work/job
- Finances
- Driving
O/E +/- OT (home) assessment and
Inx
tests (MMSE, CAM, GDS etc)
Driving assessment
SX of BPSD
Agitation and aggression and irritability
Repetitive and inappropriate vocalisations
Sexual disinhibition
Wandering
MOOD - Depression, anxiety, apathy
Delusions and hallucinations and paranoia
Restlessness and overactivity
Aetiology of BPSD (list 5 in each category)
Biological
- Meds
- Pain
- Constipation
- Urinary retention
- Sensory impairment
- Tiredness
- Hunger, thirst
- Delirium/acute medical illness
Psychological
- Previous psychological lines (depression and anxiety)
- Premorbid personality
- Frustration
- Boredom
- Fear
Environmental
- overstimulation
- understimulation (boredom)
- Overcrowding
- consistent caregiving/ high staff changes
- provocation by others
Non pharmacological MX of BPSD
- Clarify the problem (behavioural chart - what/when/where/why, identify the behaviours you want to treat, any triggers and/or reasons for behaviour)
- Correct reversible factors - Treat medical problems and causes of disability (mobility, vision, hearing) and PAIN
- Environment - low stimulus, privacy, adequate space, staff trained in behave. mx
- Interpersonal - staff education/support/training, patient-cantered care, behavioural mx techniques, psychoeducation for staff
- Therapeutic - relaxation and behavioural mx techniques
Pharmacological MX of BPSD (mention any SEs)
Antipsychotics for aggression and delusions (risperidone, haloperidol, quetiapine, olanzapine)
SE: incr risk CV events and death
Benzos to decrease agitation
SE: incr risk falls, sedation, decr cognition
reversible causes of BPSD to consider
Drugs and alcohol + withdrawal Eyes and ears Metabolic (thyroid, Ca, Na, BSL) Emotional/psych Nutritional Trauma and tumours (subdural haem, brain tumour) Infx (HIV, neurosyphilis) Atheroma (vasc dementia)
DDX memory loss
Age associated memory decline
Mild cognitive impairment
Dementia
- AD/VD/LB/PD/FTD
Delirium
Depression
Medical problem
- thyroid
- HyperCa
- HypoNa
- Hypoglycaemia
- Brain tumour
- Infx (meningitis, enceph, neurosyphilis, HIV)
- Low B12, folate
- Low thiamine
- Medication SEs
- Drugs and alcohol
- Intoxication
- Subdural haemmhorage
- head trauma
Why is polypharmacy bad?
Drug interactions
Drug side effects
Pill burden - missed doses, wrong drug, cost
Delirium
Mortality and morbidity incr (hospital admission and prescribing errors)
Falls - hypotension (antiHTN) and benzos
Common causes of malignant bowel obstruction
Colorectal and ovarian cancers are the most common intra-abdominal cancers assoc w MBO
Breast cancer and melanoma are the most common extra-abdominal causes.
Investigations for suspected bowel obstruction
The abdominal X-ray is used to look for dilated loops of bowel, air fluid levels, or both.
The abdominal CT is useful in making the diagnosis of bowel obstruction, evaluating for complications, and staging and choosing surgical or endoscopic intervention.
+/- Endoscopy
Treatment of MBO
- Surgical (debulking, diverting colostomy, intestinal bypass, and resection)
- Resection should be considered in patients with good performance status and localised disease - Nasogastric tubes are often placed in initial treatment for decompression if symptom relief does not occur with medications. OR percutaneous gastrostomy tube OR metallic stents
- Medical therapy and palliation
- IV fluids and electrolyte replacement initially, then consider TPN
- Opioids
- Antiemetics (metaclopramide)
- Antisecretory agents (octreotide, a somatostatin analogue)
- Dexamethasone
Key physical findings in the elderly who falls
I HATE FALLING
Inflammation or deformity of joints Hypertension Auditory/visual problems Tremor (PD etc) Equilibrium Foot problems Arrhythmia, heart block or valvular disease Leg length discrepancy Lack of conditioning Illness (acute or chronic) Nutrition Gait disturbance
Common causes of falls
Intrinsic MSK - gait disturbance - pain - joint/balance disorders - muscle weakness
CVS
- Postural hypotension
- Arrhythmia
- Valvular
- IHD/MI
CNS
- CNS disorder, syncope, epilepsy
- stroke/TIA
- sensory (Visual impairment and hearing impairment, peripheral neuropathy)
OTHER
- Acute illness
- Hypoglycaemia
- psychological (fear, anxiety)
- decr cognition
Extrinsic
- environmental hazards (loose rugs, cords, uneven floor, clutter, lighting)
- footwear
Behaviour (risk activities - ladder, standing on chair etc)
Meds and other substances
- withdrawal
- intoxication
- medications
- polypharmacy
Medications that can cause falls
Sedatives (opioids, bentos) Anxiolytics TCAs Antihypertensives (digoxin) Cardiac meds C/S NSAIDs Anticholinergics Hypoglycaemics
Physical exam for falls evaluation
Vitals and orthostatic BP
Vision and hearing
Gait and balance
- one-leg balance
- timed up and go
- chair stand (arms crossed)
- Romberg’s test
- walking on heels/toes
- sternal push or shoulder tug
Neuro
Functional evaluation
- write a sentence
- lift a book
- put on and take off a jacket
- pick up a penny
- turn 360 deg and walk 15m
Falls prevention strategies
INTRINSIC Optimise medical conditions - Appropriate sensory aids - BP - foot and joint conditions - inx and mx syncope - CV PT - gait and balance training and resistance exercises
EXTRINSIC Gait aids OT home assessment w appropriate changes Low bed Proper foot wear Improve home supports
DRUGS
Vit D 1000iu daily
Medication R/V - tapering and discontinuation of sedatives, avoidance of polypharmacy
BEHAVIOUR
Advice re: reducing falls and risky behaviour
Clinical psych r/v for severe fear of falling
INJURY PREVENTION
Hip protectors
Crash pads
Education re: how to get up from fall
Management of dementia
- Multidisciplinary! (OT, PT, Speech, language therapy)
- Family meetings important
- Orientation cues
- Psych: CBT, reminiscence work, validation therapy
- Optimise vision and hearing
- Optimise other medical problems (treat RFs, chronic and acute medical problems)
- Treat BPSD SX
- Education and support for patients and carers
- Legal advice - Power of attorney
- Advice Re driving
- OT home assessment and modifications
- Community support services (district nursing, meals on wheels, house keeping tc)
- Training for staff in care homes
- Pall care in terminal stages
Medications used only for
- sec prevention (in VD)
- treat aggression or specific SX of BPSD
- Enhance cholinergic transmission in AD (cholinesterase inhibitors or NMDA antagonists)
Features of vasc dementia
Step-wise deterioration CV risk factors SX - Focal neurology - Gait disturbance - Early incontinence - Falls - Cognition (exec function, encoding) affected but memory intact - Psychological SX (depression and apathy, hallucinations, emotional lability)
Imaging will show evidence of infarct
