Care Of The Eldrely Flashcards
Differences between delirium and dementia ?
Delirium Acute onset Fluctuating course Impaired attention Decreased consciousness Usually reversible Often accompanies physical illness Hospital acquired
Dementia Chronic illness Progressive course Preserved attention Consciousness preserved Irreversible No underlying medical cause
Common causes of delirium? More rare causes?
Commonly: UTIs (and other infections) opiate side-effects (and other drugs) alcohol withdrawal hypoglycaemia hypoxia TBI post-op postictal dehydration
Rarely: hyper/hypothyroidism, Cushing’s, CVA, Addison’s, Urinary retention, heart failure, constipation, B vitamin deficiency, porphyrias,
Management of delirium ? Aggression drugs? What needs to be considered with drugs?
Adapt the ward to keep patients well orientated in time and place
-big clocks, well lit …
Optimise management - Eg Fluid monitoring / SaO2
Identify and treat underlying causes
Aggression -> de escalate and talk down
Medication - 1st -lorazepam oral and IV/IM
-then can try olanzapine, promethazine or haloperidol
Drugs are not a long term solution - max 1 week ideally
Dementia investigations in primary care? Screening tools? Tests for sub types? Secondary care ix?
FBC, U&Es, LFTs, eGFR, TFT, b12 and folate, urine, HbA1C,
Referral to specialist memory services
MMSE, 6-CIT, GPCOG
Subtype: ICD-10 and DSM-V
-special tests Eg Luria’s 3 step / FAB
Secondary care imaging - MRI>CT
How do you differentiate AD, VD and FTD ?
perfusion hexamethylpropyleneamine oxime (HMPAO) single-photon emission computed tomography (SPECT)
What is Luria’s 3 step test?
Patient asked to tap table with fist then open palm then side of open hand
Then repeat as fast as they can
What is the FAB test? What is is used for?
Frontal assessment battery
Differentiating between frontal type and AD
What criteria is used in AD diagnosis? What MMSE scores for mild / moderate / severe and drugs used?
NINCDS-ADRDA criteria
Mild (21-24), moderate (10-21) Acetylcholinesterase inhibitors (rivastigmine, donepazil, galantamine)
Severe (<10) NMDA antagonists (memantine)
What tool used for screeening of vascular dementia?
NINDS-AIREN criteria
What are Lewy bodies? Screen with? How do you minimise Parkinsonism?
Clumps of alpha-synuclein protein
International Consensu for LBD screening tool
Levodopa
Screening tool for FTD
Lund-Manchester screening tool
What causes Korsakoffs psychosis? Sx?
Chronic thiamine (b1) deficiency - usually due to alcoholism
Severe memory loss with confabulation, apathy and a lack of insight
Reversible causes of dementia ?
Psudodementia B12/ folate deficiency Hypothyroidism Syphilis Paraphernia Lyme disease NPH
Medical causes of falls risk? Social causes?
Weakness Poor vision Dizziness - CV and polypharmacy Loss of coordination Stiffness / joint function Delirium and cognitive impairment Incontinence
Social
Loss o mobility aids
Home hazards
Insufficient care
Medical consequences of falls? Social consequences/
Fracture
Heat injury
Social - fear/ anxiety, loss of independence, Medically fit for discharge patient (MFFD)
What is the difference between osteoporosis and osteomalacia?
Osteoporosis is an imbalance between bone remodelling and bone resorption, resulting in reduced bone mineral density
Osteomalacia (adult rickets) is the failure to adequately mineralise your bone, due to calcium or vitamin D deficiency
Risk factors for osteoporosis?
Elderly smoking Early, untreated menopause Underweight Inactivity Alcohol
Tool to estimate fragility fractures risk assessment?
FRAX - 10 year fracture risk
Common fractures in osteoporosis?
Spinal
NOF
Wrist
(Low blood flow ???)
Osteoporosis ix? What does the scan tell you? What diagnosis if there is reduced density but not at a level for osteoporosis?
Bloods - calcium and Vit D
Bone mineral density - DEXA scan (dual-energy-X-ray-absoptiometry)
Gives you a T-score (comparison between the BMD between patient and what’s Normal for their age/gender
Osteopenia
Management of osteoporosis?
Reduce risk of falling
-social, polypharmacy, balance and strengthening exercises
Reduce risk of fractures if they do fall
-milk, bisphosphonates
Mnemonic for causes of delirium
DELIRIUM
Drug use (introduction, dose adjustments)
Electrolyte and physiological abnormalities
Lack of drug (withdrawal)
Infection
Reduced sensory input (blind, deaf, changing env.)
Intracranial problems (stroke, post-ictal, meningitis, subdural haem.)
Urinary retention and faecal impaction
Myocardial (MI, arrhythmia, HF)
Ways of managing the environment in delirium?
Soft lighting Clocks and calendars Sleep hygiene - night time sleeping Avoid multiple rooms / wards Minimise provocation
Patient came in with UTI and subsequent delirium maybe over the top of dementia. After managing UTI her MMSE score has improved but she is still confused
What are the next steps? What is this? Aspects of it?
Comprehensive geriatric assessment
Identifies health problems and establishes management plans in older patients with frailty
“An interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old
The aim is to develop a coordinated, integrated plan for treatment and long-term support”
Physical health - includes pain and underlying illness
-Medication review
Mental health - memory, mood cognition, capacity
Social aspects
- informal (family, friends)
- formal (social services, meals, day care)
[SPF ME - aspects]
Functional aspects - can they use public transport / technology?
Environment - state of housing, facilities
Who is in the CGA team?
Chair OT Geriatrician Social worker Physiotherapist
Jasper is 76. He has a left hemiparesis from a previous stroke
Brought to A&E by home carer having fallen in the bathroom at home
He was on floor for 18 hours as he could not get up
What are the complications of a long lie following a fall?
Pressure ulcers
Dehydration
Rhabdomyelosis - damaged skeletal muscle breaks down rapidly
-> muscle pain, weakness, confusion, vomiting
-> tea coloured urine and arrhythmia
-> myoglobin can -> kidney failure
Pressure ulcers Ix? Mx?
Ix: CRP, ESR WCC Swabs Blood cultures X-ray for bone involvement
Management: Antibiotics Wound dressing Pain relief Debridement if grade 3/4
Bleeding from gums and excessive bruising - diagnosis? Mx? How do you assess nutritional status?
what are the methods of feeding ?
Vit C deficiency
Correct deficiency and MDT approach to address malnourishment
MUST screening tool
Oral, PEG, total parental nutrition
What is reseeding syndrome? Biochemical features?
Complications?
Mx?
Metabolic disturbance as a result of reinstitution of nutrition to patients who are starved / severely malnourished
Biochemical features Hypophotphataemia Hypokalaemia Thiamine deficiency Abnormal glucose metabolism
Complications
Arrhythmia, coma, seizures, cardiac failure
Mx
Monitor blood biochemical
Commence refereeing with guidelines
4 I’s of geriatrics
Immobility
Incontinence
Incompetence
Impaired homeostasis
85 year old man with 2/12 Hx diarrhoea. Wife noticed decline in cognition. Palpable liver edge. Urine dip shows nitrites, protein and leucocytes. On admission, he is very confused.
Give 2 causes for his confusion
What test would you do to assess his mental state?
What 3 things could the nurses do to help?
Wife unable to cope at home.
How would you assess the situation before discharge?
Infection / metabolic abnormalities, old age
MMSE
Clocks, good lighting, not move room / ward
CGA, MDT input, cares, physio, occupational therapy
