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Phase 3A medicine > COTE FC from ppt > Flashcards

COTE FC from ppt Flashcards

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1
Q

define frailty

A

-state of increased vulnerability resulting from ageing-associated decline in functional reserve

-across multiple physiological systems

-resulting in compromised ability to cope with everyday or acute stressors

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2
Q

what is the impact of frailty on elderly people and how does it change how they need to be cared for

A

different type of doctor - geriatricians are experts in frailty

poor functional reserve - trivial insult to a younger person has a large impact on an older person

failure to intergrate responses in the face of stress

vulnerable to decompensation when faced with illness, drug side effects and metabolic disturbance

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3
Q

what are the most common presenting complaints in geriatric medicine

A
  1. falls
  2. confusion
  3. fever/infection
  4. new incontinence
  5. ‘off legs’ - used to be able to walk and now can’t
  6. ‘failed DRT (discharge response team)
  7. chest pain/SOB
  8. urinary symptoms - pain, changes, incontinence
  9. off food, generally unwell
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4
Q

what are the geriatric giants

A

4 I’s
1. instability (falls)
2. immobility
3. intellectual impairment (confusion)
4. incontinence

not diagnoses - more general/vague - normally indicative of underlying problems

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5
Q

what is the comprehensive geriatric assessment

A

not a form to fill in/booklet - process of what is done in geriatrics

multidimensional, MDT diagnostic process

focussed on determining a frail older person medical, psychological and functional capability

development of a co-ordinate, intergrated plan for treatment and long term follow up

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6
Q

what are the 4 components of the comprehensive geriatric assessment

A
  1. medical assessment
  2. functional assessment
  3. psychological
  4. social and environmental assessment
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7
Q

what is the medical assessment made up of

A

doctor, nurse, pharmacist, dietician, SALT

problem list, comorbs, medicaton review, nutritional statuses

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8
Q

what makes up the functional assessment

A

OT, PT, SALT

assesses ADLs, activity, exercise status, gait, balance

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9
Q

what is the psychological assessment comprised of

A

doctor, nurse, OT, psychologist

cognitive status testing, mood/depression testing (PHQ-9 questionnaire)

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10
Q

what is the social and environmental assessment comprised of

A

OT and social worker if needed

informal support needs and assets, care resource eligibility, home safety

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11
Q

what are the features of delirium

A

acute onset
fluctuating course
inattention
altered level of unconsciousness
usually reversible
associated with underlying medical cause

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12
Q

what are the features of dementia

A

chronic illness
progressive course
no clouding of consciousness
no underlying/reversible cause

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13
Q

name an assessment tool used for delirium

A

4-AT

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14
Q

what causes delirium

A

infection
drug use - withdrawal or new medications interaction
reduced sensory input - blind, deaf, changing environment
intracranial problems - stroke, seizures, haemorrhages
electrolyte imbalances
constipation
urinary retention
heart problems - MI, arrhythmia

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15
Q

how is delirium managed

A

treat underlying cause

manage the environment

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16
Q

name some ways in which the environment can be altered to help delirium

A

clocks and calendars to maximise orientation

ensure hearing aids/glasses are worn

photos of family membrers

consistency of staff members

quiet bay/side room is possible

sleep hygiene (promote night sleep, not daytime)

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17
Q

what is the role of the comprehensive geriatric assessment

A

identifies health problems and establishes management plans in older patients wit frailty

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18
Q

who makes up the comprehensive geriaric assessment team

A

geriatrician
social worker
physiotherapist
occupational therapist

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19
Q

what are the complications of a long lie following a fall

A
  1. pressure ulcers
  2. dehydration
  3. rhabdomyolysis
  4. hypothermia
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20
Q

how do you investigate pressure ulcers

A

CRP, ESR
WCC
swabs
blood cultures
X-ray for bone involvement

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21
Q

how are pressure ulcers managed

A

ABx
wound dressing
pain relief
debridement if grade 3/4

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22
Q

what is osteoporosis

A

decreased bone mineral density due to imbalance between remodelling and resorption

increases risk for fractures - particularly spine, hip and NOF

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23
Q

what are some risk factors for osteoporosis

A

smoking
early menopause
steroid use
underweight
inactivity
alcohol
ALL ELDERLY PEOPLE

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24
Q

how is osteoporosis managed

A

bisphosphonates (zoledronate, alendronate)

IV once a year or oral once a week - (empty stomach, stay upright for half an hour as may = oesophagitis)

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25
what is a tool used for assess nutritional status
MUST screening tool (malnutritional universal screening tool)
26
what is re-feeding syndrome
metabolic disturbances as a result of reintroduction of nutrition to patients who are starved/severely malnourished
27
what are the biochemical features of refeeding syndrome
hypophosphataemia hypokalaemia thiamine deficiency abnormal glucose metabolism
28
what are some complications of re-feeding syndrome
cardiac arrythmias coma convulsions cardiac failure
29
how is re-feeding syndrome treated
monitor blood biochem commence re-feeding with guidelines recognise electrolytes (phosphate, K+, Mg) monitor glucose and Na levels supportve care refer to nutritional support team/dietician
30
what are some risk factors for pressure ulcers
age peripheral vascular disease immobile a long time dehydration obesity malnourishment
31
how can you prevent pressure ulcers
keep patient mobile change bed positon special mattress - pressure re-distributing mattress barrier creams regular skin assessment
32
name 2 treatmen that will improve bone health
bisphosphonates vitamin D and calcium supplements (exercise - impact like walking, not swimming)
33
what are some environmental causes of falls in elderly people
loose rugs pets furniture unstable footwear
34
what are some power/balance causes of falls in elderly people
inactivity leading to - muscle weakness dizziness/loss of balance/loss of proprioception (vertigo) pain/MS - osteoarthritis previous fall leading to decreased confidence
35
what are some cardiovascular causes of falls in elderly people
vasovagal syncope (faint) situational syncope - micturition (old men, night time) postural hypotension MI arrhythmia dehydration/shock
36
what are some neurological causes of falls in elderly people
stroke PD gait disturbance visual impairment peripheral neuropathy myopathy (statin or steroid myopaty)
37
what are some medications that increase risk of falls in elderly people
benzodiazepines - sedatve so impair coordination diuretics anti-Hypertensive - ACEi, CCB, Beta-blocker antidepressant antipsychotic polypharmacy
38
what are some other causes of falls in elderly people
infection/sepsis delirium hypoglycaemia incontnence alcohol - intoxication, neuropathy, Korsakoff's/wernicke's
39
what are the three main features of Parkinson's
1. bradykinesia 2. rigidity (lead-pipe, cog-wheel) 3. tremor
40
list three differentiating features of a Parkinsonian tremor
pill rolling worse at rest reduced on distraction reduced on movement worse on one side (asymmetrical)
41
what is the underlying pathophysiology of Parkinson's
loss of dopaminergic neurones in the substantia nigra
42
what class of drug is normally combined with L-dopa therapy to prevent peripheral side-effects
carbidopa - a dopa decarboxylase inhibitor
43
name 3 complications of L-dopa therapy
development of choreiform movements (L-dopa induced dyskinesia) become tolerant to the medication - even if the dose is increased the effect will become less confusion hallucinations postural hypotension on starting treatment
44
name 4 cardiac conditions that may cause an embolic CVA
1. AF 2. infective endocarditis 3. atrial septal defect / patent foramen ovale 4. mitral regurg 5. aortic or mitral valve disease 6. valve replacement
45
Other than an ECG and CT head in stroke, what 3 other investigations might you consider and why
carotid artery doppler - carotid artery stenosis could = stroke and should be treated promptly lipid profile - could be hypercholesterolaemia as a RF for stroke clotting screen - may indicate increased risk of thrombosis or haemorrhage ECHO - exclude cardiac sources of emboli
46
what ABCDs score is considered 'high risk' for a stroke and what should be done
>4 = high rsik - aspirin - 100mg daily - immediately - specialist referral within 24 hours of system inset - secondary prevention measures (statins, antihypertensive) crescendo TIAs (two or more episodes in a week) should be treated as high risk, regardless of ABCDs score
47
what should be done for someone with an ABCDs score of <3
specialist referral within 1 week of symptoms onset, including decision of brain imagening if vascular territory or pathology is uncertain - refer to brain imaging
48
what are he components of the GCS
1. best eye opening response 2. best verbal response 3. best motor response (how well they localise pain)
49
list 6 causes of delirium
infection polypharmacy urinary retention constipation dehydration electrolyte imbalance medication withdrawal stroke MI B12 deficiency
50
list 3 non-invasive investigations you would do for someone with suspected delirium
FBC ECG to exclude MI U&E urine dip to exclude UTI CXR - exlcude pneumonia
51
list 4 causes of hyponatraemia
dilutional effect - SIADH, hypervolaemia/failure excess, NSAIDS (promote water retention), oliguria renal failure (dilution) sodium loss - Addison's disease, diarrhoea and vomiting, osmotic diurese (DM, diuretic excess), severe burns, diuretic stage of acute renal failure
52
name 4 symptoms of hypocalacaemia
muscle cramps/spasms tetany seizures parathesia cardopedal spasm laryngospasm, bronchospasm
53
name 4 symptoms of hypercalacemia
BONES, STONES, MOANS, GROANS bone pain, fractures renal stones (renal colic), polyuria, polydipsia, dehydration drowsiness/coma muscle weakness depression N+V, weight loss, anorexia constipation, abdo pain
54
what MMSE supports a diagnosis of dementia
<25 supports dementia
55
what other cognitive assessments tools may be used
GP-COG Addenbrooke's 6-CIT AMT MOCA
56
name 4 different types of dementia and their key features
Alzheimers - agnosia, apraxia, amnesia, aphasia vascular dementia - stepwise progression of symptoms following ischaemic brain injury lew body dementia - sleep behaviour, falls, impaired consciousness, visual hallucinations, Parkinsonism frontotemporal dementia - memory fairly preserved, extreme personality changes and disinhibition
57
list 4 blood tests you would do to exclude treatable causes of dementia
Vit B12, thiamine, folate TFT FBC looking for anaemia syphilis serology (neurosyphilis) LFT (hepatic encephalopathy, alcoholism)
58
what is donepezil and what types of dementia can it be treated
acetylcholinesterase inhibitor (others are rivastigmine and galatamine) can only be used to treat Alzheimer's alternative medication - NMDA-receptor antagonist - blocks glutamate (memantine)
59
what are 2 types of subtypes of delirium
hyperactive => agitates, inappropriate behaviour, hallucinations hypoactive => lethargy, reduced concentration
60
what are some risk factors for delirium
old age cognitive impairment frailt/multiple comorbidities significant injuries (e.g hip) functional impairment history of alcohol excess sensory impairment (deaf, blind) poor nutrition lack of stimulation terminal phase of illness
61
how does delirium present
acute behavioural change diorganised thinking/altered perception altered level of consciousness falling loss of appetite
62
what bedside tests would you do for someone with delirium
O2 sats BP Temp ABG/VBG
63
what investigations would you do for someone with delirium
FBC, LFT, U&E CRP/ESR sputum culture Folate, B12 HbA1C TFT CXR, ECG, urinalysis
64
how regularly should bisphosphonates be checkes
after 5 years - treatment reassessed, update FRAX score and DEXA scan
65
what are the reasons to keep treating with bisphosphonates
on steroids age > 75 previous hip/vertebral fractures further fractures on treatment high risk on FRAX score DEXA scan T-score <-2.5 after treatment
66
how do bisphosphonates work
inhibition of osteoclasts
67
list 3 adverse effects of bisphosphonates
oesophagits osteonecrosis of the jaw increased risk of atpical stress fractures of the proximal femoral shaft in patients taking alendronate
68
how are DEXA scan scores interpreted
-1 to + 1 = healthy -1 to -2.5 = osteopenia <-2.5 = osteoporosis <2.5 and a current fragility fracture = severe osteoporosis
69
what are the components of the FRAX scoring system
parent hip fracture height and weigth (BMI) smoking alcohol >3 units/day steroids previous hip fracture femoral neck bone mineral densit female gender age RA secondary osteoporosis
70
how is malnutrition diagnosed
BMI <18.5 Kg/m^2 unintentional weight loss >10% in last 3-6 months BMI <20Kg/M^2 plus unintentional weight loss >5% within the last 3-6months
71
what are some causes of malnutrition
inadequate nutritional intake (starvation) increased nutrient requirements (cancer, sepsis, injury) inability to utilise ingested nutrients (malabsorptions) increased loss (vomiting, diarrhoea) combination of all of them
72
what tests are important to be done before commencing feeds
U&Es LFTs ECG
73
what are some clinical features of re-feeding syndrome
CVS - arrhythmia GI - abdo pain, constipation, vomiting, anorexia MSK - weakness, myalgia, rhabdomyolysis, osteomalacia resp - SOB, ventilator dependence, resp muscle weakness neuro - weakness, paraesthesia, ataxia metabolic - infections, thrombocytopenia, haemolysis, anaemia other - liver failure, Wernicke's encephalopathy
74
what needs to be considered in a best interests decision
whether person is likely to regain capacit and decision can wait how to encourage and optimise the participaton of the person in the decision past and present wishes, feelings, belief and values of the person and other relevant factors views of other relevant people (family etc)
75
what is the role of an advanced directive
allows people who understand the implications of their choices to state their treatment wishes in advance they can authorise specific procedures they can refuse treatment in a predefined future situation
76
77
what factors would mean the advanced directive had less of a legal binding
if there is an advanced request for treatment this does not have the same legal binding as a refusal of treatment but if it's the patient's known wish to be kept alive then reasonable efforts (nutrition, hydration) should be made
78
what is deprivation of liberty
occurs when a person does not consent to care or treatment - cannot consent to treatment/care but they are having it anyway for example a person with dementa who is not free to leave a care home and lacks capacity to consent to this
79
what is a lasting power of attorney
a document which a person can use to nominate someone else to make certain decision on their behalf when they are unable to do so themselves it can be financial/about estate or medical/health decisions to be valid - needs to be registered with the office of the public guardian
80
what is the role of an independent mental capacity advocate (IMCA)
commisioned from independent organisations by the NHS and local authorties to ensure the MSA is being followed Role = support and represent the people who lack capacity and do not have anyone else to represent them in decisions (i.e long term accomodation or serious medical treatment)
81
what is the definition of postural hypotension
a drop of >20/10 mmHg w/in 3 mins of standing occurs in 30% of patients over 70
82
what are some causes of postural hypotension
medications - diuretics, antihypertensives, antidepressants, polypharmacy cardiac - aortic stenosis, arrhythmias, MI, cardiomyopathy, CHF, anaemia endocrine - diabetes insipidus, hypoadrenalism, hypothyroid, hypo..anything neuro - PD and PD+ syndromes blood loss, dehydration, shock
83
how does postural hypotension present
asymptomatic falls/syncope dizziness light-headiness blurred vision weakness fatigue palpitations headaches
84
how is postural hypotension investigated
lying and standing blood pressure investigate for medical causes - medication review, blood test
85
how is postural hypotension managed
drink lots of water avoid large meals and alcohol exercise stand slowly sleep with head raised pharmacological - fludrocortisone, midodrine (autonomic dysfunction only)
86
how are pressure ulcers classified
grade 1 - non-blanching erythema with intact skin grade 2 - partial thickness skin loss involving epidermis, dermis or both (abrasion/blister) grade 3 - full thickness skin loss involving damage/necrosis of sub-cut tissue grade 4 - extensive loss, destruction/necrosis of muscle, bone or support structures unstageable - depth unknown, base of ulcer covered by debris
87
what are the 2 major metabolic components of calcium homeostatis
vit D PTH
88
what is the role of vitamin D
increased Ca2+ absorption in gut increased Ca2+ release from the bone
89
where is PTH released from and what triggers its release
secreted from the chief cells of the parathyroid gland in response to low serum Ca2+ levels (detected by calcium sensor cells in the parathyroid glands)
90
what is the role/actions of parathyroid hormone
acts to increase Ca2+ levels causes increase osteoclast activity increases intestinal Ca2+ absorption increased vit D activation increased renal tubule re-absorption of Ca2+
91
how is osteoporosis defined
reduction in bone mineral density and micro-architectural deterioration of bone tissue with a consequent increase in bone fragility and suceptibility to fracture BMD>2.5 SDs below the mean is diagnostic T-score <-2.5
92
what are the 4 common sites of osteoporosis related fractures
1. thoracic vertebra - may lead to kyphosis and loss of height 2. lumbar vertebra 3. proximal femure 4. distal radius (Colles' fracture)
93
what T score would be seen in someone with osteopenia
-1 to -2.5 if > -1 then normal

Phase 3A medicine (5 decks)

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