AgedCareCheck Flashcards
(29 cards)
What are the risk factors for falls in the elderly?
Intrinsic
OH GAY CHIMP
Orthostatic hypotension
Gait disturbance
Cognitive impairment
History of Incontinence
Musculoskeletal challenges- proximal weakiness? stair climbing?
Postprandial hypotension
EXTRINSIC
FREC GLAM
Footwear
Restraints
Environmental hazards
CLUTTER!
Glasses
Meds - polypharm, psychotropics
General questions: How are you managing at home
How are you managing ADLs
Are you driving
Examination in assessment of older person?
blood pressure (BP) – checking for postural drop is important in elderly patients and particularly in a person with a history of falls. It is also important to check the pulse carefully.
body mass index (BMI), although this is not as accurate in older people because of the difficulty measuring an accurate height
full cardiovascular system examination
neurological examination including gait, balance, motor performance, tone and reflexes, peripheral sensation, proprioception, cognition, visual acuity and fields
condition of his feet and footwear
hearing impairment
driving ability – your examination at this consultation will contribute to this assessment and you could address this problem specifically at a subsequent appointment. (you can use a ‘trail making test’ referral initially)
MMSE or minicog
How would you manage a patient in a RACF with breathlessness secondary to cancer
NON PHARM:
energy conservation techniques – referral to an occupational therapist could help
diaphragmatic breathing techniques – referral to a physiotherapist could help
adequate ventilation in the RACF with the help of RACF staff (eg fan, open window, cool face washer)
addressing underlying anxiety and fears with the patient and family/carers (with the patient’s consent).
PHARM
intermittent dyspnoea (patients who never had opioids previously) – 1–2.5 mg orally as necessary of immediate-release morphine
continuous dyspnoea – 1–2.5 mg orally every four hours of immediate-release morphine or 5–10 mg orally twice a day of modified-release morphine (titrated to effect).
Use morphine with caution for patients with renal failure, particularly older patients.
Treat Constipation eg:
docusate with sennoside B 100 + 16 mg orally once or twice daily
Treat nausea and vomiting PRN:
metoclopramide – up to 10–20 mg orally four times a day
haloperidol – 0.5–2.5 mg orally twice a day.
OXYGEN THERAPY:
if less than 90 in following:
at rest
during minimal exertion
during an acute event (active infection)
to facilitate hospital discharge at the end-of-life
if patient or family are distressed by its absence.
How do you transfer oral doses of morphine to subcut? B/Through
S/Cut is 1/3 the dose
B/Through is 1/6 th
Doses of morphine for cancer PAIN
immediate-release morphine – 5–10 mg every four hours
modified-release morphine – 10–15 mg twice daily.
THis is in opiate naive
Could also use: PCM and NSAIDS
Pregabalin for pain refractory to other analgesics
Bisphonsphonates can help bone pain esp with myeloma and breast cancer
What meds are used for terminal secretions? What is the risk
Glycopyryllate and hyoscine
howevere hyoscine can cross the BBB and cause a delerium
What meds are used for terminal restlessness
Benzodiazepines – clonazepam 0.5 mg sublingually or midazolam 2.5 mg subcutaneously
How would you offer bereavement support to a patient?
follow-up bereavement support from a trusted GP and members of the general practice team. This can involve a phone call or card sent after the death, and face-to-face contact with those identified as needing more support.
Local support organisations (eg Cancer Council Victoria) may organise support groups for bereaved relatives.
Some family members and close friends may require more formal support. Organisations such as the Australian Centre for Grief and Bereavement can offer support through support groups and individual grief counselling in various locations in Australia.
Patients with comorbid psychiatric illness or bereavement disorder may also benefit from a referral to a psychologist with experience in complicated bereavement, which may be facilitated by a GP Mental Health Plan for eligible patients.33 In complex cases, referral to a psychiatrist may also be warranted.16
What are possible issues with polypharmacy and multimorbidity?
Don is not taking his medications as prescribed, either by
not taking the right dose
not taking the medications at the right time or consistently
crushing his medications
Don is experiencing drug–drug interactions caused by
hyper-polypharmacy
additional prescribed medications not listed
complementary and alternative medications not listed
- inappropriate prescribing has occured*
- specific medication is not working*
- dosage is not appropriate.*
How can polypharmacy initially be investigated
Home medicines review (MBS 900)
Reasons for non adherence
fear: patients may be frightened of potential side effects; they may have witnessed side effects experienced by someone else who was taking the same, or a similar, medication and believe the medication caused the problems
side effects: patients may attribute side effects of one medication to a number of medications and cease taking them all
cost: patients may not fill medications initially or ration what they do fill to extend their supply
misunderstanding: patients may not understand the need for the medication, the nature of the side effects or the time it will take to see positive results; failure to see immediate improvement may lead to premature discontinuation
too many medications: the greater the number of different medications prescribed and the higher the dosing frequency, the more likely a patient is to be non-adherent
lack of symptoms: patients who do not feel any differently when they start or stop their medication might see no reason to take it
worry: concerns about becoming dependent on a medication can also lead to non-adherence
depression: patients who are depressed are less likely to take their medications as prescribed
mistrust: patients may be suspicious of their doctor’s motives for prescribing certain medications because of media coverage and pharmaceutical companies’ influence on prescribing patterns
belief systems: a belief that prescription medications are toxic and are not natural may lead to trials of complementary medications.
A diabetic patient stops all their BP meds including ACe - risks
Rebound hypertension
microalbuminuria from ceasing ace
Specific ways of reducing intentional non adherence
Patient education, shared decision making, pharmacist support and motivational interviewing reduce intentional non-adherence
HOw can deprescribing occur in GP
Deprescribing is a structured process with consent from the patient/carer explaining the rationale and steps to take if symptoms recur and information about alternative non-medication strategies that may be used to control symptoms.45 A written tapering plan is desirable, especially for the classes of medication that require slow tapering to avoid either a return of disease symptoms or withdrawal symptoms (eg opioids, proton pump inhibitors).
According to the PLST (progressively lowered stress threshold) in Dementia - which factors can trigger agitation?
fatigue
change of routine, environment or carer
internal or external demands that may exceed functional capacity
misleading stimuli or inappropriate stimulus levels
affective response to perceptions of loss, including anger or depression
physical stressors, such as acute illness, adverse reactions to medication, infection, pain or discomfort.
What is the Need Driven Behaviour model for agitation in known dementia
Unmet needs drive agitation
What tools are available to monitor behavioural and psychological symptoms of Dementia BPSD
The Neuropsychiatric Inventory is comprehensive and is a good measure of BPSD. The Behavioural Pathology in Alzheimer’s Disease rating scale is another good alternative to measure behavioural disturbances in dementia
How can BPSD be managed?
Therapeutic recreation – leisure activities that improve daily functioning, independence and wellbeing. Examples include cooking activities, gardening or social interventions.
Reminiscence-based interventions – using life histories and experiences to improve wellbeing. Examples include using CDs, DVDs or books to remind the person of their family and past.
Exercise interventions – physical activity such as walking, which targets balance, mobility, flexibility and/or strength.
Music interventions – soothing or familiar music may help improve agitation.
Animal interventions – interaction between the person with dementia and a trained animal, such as a dog or cat, in a controlled environment. Interventions involving plush toys or robotic animals are also included in this category.
Sensory interventions – for example, aromatherapy, bright-light therapy and multisensory stimulation.
Touch therapies – acupressure and massage for relaxation for the person with dementia.
Models of care – specific care plans implemented within RACFs including emotion-oriented interventions or addressing unmet biopsychosocial needs.
Environmental interventions – adjusting the physical environments for people with dementia and BPSD.
Pharm for BPSD/Agression?
significant distress to themselves or others’ may be offered antipsychotics (eg risperidone). The use of risperidone should be reviewed every 1–3 months.
Should benzos or other drugs be used for BPSD
Not really. (use risperidone)
Benzodiazepines
Evidence for the use of benzodiazepines is lacking; therefore, they should only be used for acute crisis situations when other methods have failed. In practice, they are prescribed as PRN (‘as needed’) medications and used by the nursing staff when the patient’s agitation or aggression becomes uncontrollable.58
Other medications
There is some evidence that citalopram and memantine are effective in managing agitation and aggression in people with dementia.57
Side effects of antipsychotics
Side effects of antipsychotics include further cognitive decline, somnolence, insomnia, extrapyramidal signs, gait disturbance, oedema, metabolic syndrome, incontinence, cerebral adverse events and falls
Side effects of Benzos
Side effects of benzodiazepines include sedation, falls, confusion, ataxia, dizziness and leukopenia.
What are you monitoring every 1-3 months for demented patients on antipsychotic meds
Assessment
Related adverse effect or reason for assessment
Behaviour
Documentation of previous attempts at ceasing the antipsychotic and outcomes of previous attempts
Agitation, anxiety
Non-pharmacological methods used that have failed
Pharmaceutical Benefit Scheme criteria
Bowel actions
Constipation
Sleep
Somnolence, insomnia
Weight measurement
Weight gain
Pain
Extremity pain, headache
Cardiovascular system examination (consider electrocardiogram)
Bradycardia/QT interval prolongation
Consider blood tests
Agranulocytosis
