Elderly Medicine Flashcards
1
Q
What should be included in a medical history?
A
- Current reason for his admission
- Falls history
- Assessment of cognition
- Continence assesment - bladder and bowels assessment
- PMH and disease severity
- Current medication list and complicance
- Drug allergies
- Social and functional history - who do they live with. How are they supported and by whom. Mobilising. Shopping cleaning
- Alcohol and smoking
- Systemic enquiry
- Wishes and advanced decisions
2
Q
What should be used when assessing old people?
A
Comprehensive Geriatric Assessment
3
Q
What does Comprehensive Geriatric Assessment look at?
A
- Problem list
- Medication review
- Nutritional status
- Mental health
- Functional capacity
- Social circumstances
- Environment
4
Q
What is poly pharmacy?
A
Looking at 6 or more drugs being prescribed at any one time.
5
Q
What should you do whenever you prescribe a drug?
A
- Check the correct agent is prescrined
- Drug allergies
- Interactions with other drugs
- Use genetic drug names and write them down in capitals
- Don’t use abbreviations
- Dose, frequency and times and route of administration are clearly identified. Include a start date
- Be cautious using decimal points
- Units rather than u
- Print name as well as signing if on a paper chart
- Review medications daily
- Stop those not needed
6
Q
What is the importance of discharge planning?
A
- Agree care pathways of the older persons
- Give a patient centred perspective approach
- Discharge arrangements should maximise the quality of life and promote independence
7
Q
What is section 2?
A
- Section 2 - referral is made to social services to assess funding. e.g a care home or direct payments.
- Social worker is then allocated to the patient/ service user and will be responsible for putting together an appropriate packet of care
8
Q
What is section 5?
A
- Sent by nursing staff to social services alerting them to the fact that the patients has been declared as ‘medically stable for discharge’
- Once recieved the designated socail worker is expected to take decisive action towards discharge
9
Q
What do discharges involve?
A
- Medication to take home
- Transport
- Therapy assessment - OT, physio
- Restarting package of care
- Outpatient/ user appointment
- District nurse referral if required/ palliative or community led referral if warranted
- Transfer back letter for residential nursing home
10
Q
Why do discharges fail?
A
- Patient/ user health complications
- Communication breakdown
- Family decisions
- Decisions around funding
11
Q
What are the geriatric giants?
A
- Falls
- Incontinence
- Dementia/ delirium
- immobility
12
Q
How are falls usually classed?
A
- Syncopal
- Non syncopal
13
Q
What questions should be asked in a falls history?
A
- What were they doing?
- How did the fall happen?
- How did you feel before the fall?
- Dizziness or lightheadedness
- Loss of consciousness?
- cardiac sx?
- Did they have weakness anywhere? DId you lose control of your waterworks?
- Has this happened before?
- Have they had any near misses before?
- What medication are they on? sedatives, hypoglycaemic, opiates, opiates, cardiac medicatiom/
- How do they normally mobilise?
14
Q
What should a falls examination focus on?
A
- Mobility assessment - mobilise, with what and gait
- Cardiovascular examination - ECG/ lying and standing BP
- Neurological examination
- MSK examinartion - joint function
- Assess osteoporosis risk!
15
Q
What is delirium?
A
- Acute confusional state, with sudden onset and fluctuating course
- Develops over 1-2 days and is recognised by a change in consciousness
- Can be caused by an underlying medical problem, substance intoxication and substance withdrawal
- Common in older persons, with sensory and cognitive impairment
- It can be:
- Hyperactive: restlessness, mood lability, agitation, or aggression
- Hypoactive: slow and withdrawn
16
Q
What are the clinical features of delirium?
A
- Globally impaired cognition, perception, and consciousness which develops over hours/days
- Marked memory deficit, disordered or disorientated thinking, and reversal of the sleep–wake cycle.
- Some patients experience tactile or visual hallucinations.
17
Q
What are some of the causes of delirium?
A
- Surgery
- Systemic infection: pneumonia, uti, malaria, wounds, iv lines.
- Intracranial infection or head injury.
- Drugs/drug withdrawal: opiates, levodopa, sedatives, recreational.
- Alcohol withdrawal (2–5d post-admission; ↑lfts, ↑mcv; history of alcohol abuse).
- Metabolic: uraemia, liver failure, Na+ or ↑↓glucose, ↓Hb, malnutrition (beriberi, p[link]).
- Hypoxia: respiratory or cardiac failure.
- Vascular: stroke, myocardial infarction.
- Nutritional: thiamine, nicotinic acid, or b12 deficiency.
18
Q
What are some of the risks associated with delirium
A
- Increased mortality
- Prolonged hospital admission
- Higher complication rates
- Institutionalisation
- Increased risk of developing dementia
19
Q
What are the 8 signs of delirium?
A
- Disordered thinking
- Euphoric, fearful, depressed or angry
- Language impaired
- Illusions, delusions, hallucinations
- Reversal of sleep awake cycle
- Inattention
- Unaware/ disorientated
- Memory deficits
20
Q
How is delirium investigated?
A
- Look for the cause (eg UTI, pneumonia, MI)
- Bloods: FBC, UE, LFT, blood glucose, ABG, septic screen (urine dipstick, cxr, blood cultures)
- Further investigations: ECG, malaria films, LP, EEG, CT
21
Q
What are some of the RFs for delirium?
A
- >65y
- Dementia/previous cognitive impairment
- Hip fracture
- Acute illness
- Psychological agitation (eg pain)
22
Q
How is delirium managed clinically?
A
- Reorientate the patient: explain where they are, who you are at each encounter; hearing aids/glasses. Visible clocks/calendars
- Visits from friends and family
- Monitor fluid balance and encourage oral intake
- Look for constipation.
- Mobilize and encourage physical activity.
- Practise sleep hygeine: restrict daytime napping, minimize night-time disturbance.
- Avoid or remove catheters, iv cannulae, monitoring leads and other devices (Î infection risk and may get pulled out).
- Watch out for infection and physical discomfort/distress.
- Review medication and discontinue any unnecessary agents.
-
Pharmacological: Sedation: only if the patient is a risk to their own/other patients’ safety (never use physical restraints).
- Haloperidol 0.5–2mg,
- Chlorpromazine 50–100mg po if poss: avoid in elderly and alcohol withdrawal
- Avoid antipsychotics with Parkinson’s disease or Lewy body dementia
23
Q
What is dementia?
A
- A neurodegenerative syndrome with progressive decline in several cognitive domains
- Occurs over several months
- Affects many different areas of function: retaining new information, managing complex tasks, language and word finding, behaviour, orientatio, recognition, ability to self care and reasoning
24
Q
What are the types of dementia?
A
- Alzheimers Disease - Most common (75%)
- Vascular dementia (25%)
- Lewy body dementia (15-25%)
- Parkinson’s disease with dementia
- Frontotemporal dementia
25
Q
How is dementia diagnosed?
A
-
History from the patient with a thorough collateral narrative:
- Timeline of decline and domains affected
- Activities of daily living
-
Cognitive assessment:
- Validated dementia screen: AMTS
- Mental state examination: anxiety, depression, or hallucinations
-
Investigations: ↑tsh/↓b12/↓folate, ↓thiamine (eg alcohol), ↓Ca2+.
- MSU, FBC, ESR, UE, LFT, glucose
- MRI: subdural haematoma, normal-pressure hydrocephalus11), vascular damage or structural pathology.
- Functional imaging (FDG, PET, SPECT)
- Consider EEG: suspected delirium, frontotemporal dementia, cjd, or a seizure disorder.
26
Q
What is Alzheimers disease?
Who does it affect?
How does it present?
A
- Most common dementia form
- Insidious onset with slow progression
- Adults: >40
- CT Brain imaging may show hippocampal/ cortical atrophy
- Plaques and neurofibriliary tangles
Presentation
- Behavioural problems
- Progressive, and global cognitive impairment: visuo-spatial skill, memory, verbal abilities, and executive function (planning)
- Anosognosia—a lack of insight into the problems engendered by the disease, eg missed appointments, mishandling of money.
- Later: irritability; mood disturbance (depression or euphoria)
- Behavioural change: aggression, wandering, disinhibition)
- Psychosis (hallucinations or delusions)
- Agnosia (may not recognize self in the mirror).
27
Q
What is the cause or pathophysiology of Alzheimers?
A
APP (amyloid precursor protein) degradation
↓
B amyloid peptide accumulation in neurones
↓
Neuronal damage + neurofibrillary tangles
↓
↓ ACh neurotransmitter ↓
28
Q
What are the sx of Alzheimers?
A
- Progressive, and global cognitive impairment
- Visuo-spatial skill, memory, verbal abilities, and executive function (planning)
- Anosognosia —a lack of insight into the problems engendered by the disease
- Irritability and mood disturbance (depression or euphoria)
- Behavioural change (aggression, wandering, disinhibition)
- Psychosis (hallucinations or delusions)
- Agnosia (may not recognize self in the mirror).
29
Q
What are the RFs for Alzheimers?
A
- 1st-degree relative with AD
- Down’s syndrome
- Vascular risk factors: ↑bp, diabetes, dyslipidaemia, ↑homocysteine, af
- ↓physical/cognitive activity; depression; loneliness
- Genetics: apoe4 allele on chromosome 19
30
Q
How is Alzheimers managed?
A
- Mild: Refer to a specialist memory service, group cognitive stimulation therapy
-
1st: Acetylcholinesterase inhibitors:
- Donepezil
-
SE: peptic ulcer disease + heart block - check sx + perform ECG
- Rivastigmine
- Galantamine
- 2nd: memantine (NMDA-r antagonist)
- BP control: HF 2x ↑risk
- Anti psychotics: only if pt are a risk, severe agitation etc.
31
Q
What is vascular dementia?
A
- Second most common
- Chronic progressive disease causing cognitive impairment.
- Cumulative effect of many small strokes: sudden onset and stepwise deterioration
- Affects executive functions of the brain such as planning more than memory.
- Early changes: Motor and mood changes
- Look for evidence of arteriopathy
-
Vascular RFs: >60, obesity, hx of stroke, smoking, hypertension
- Others: DM, high cholesterol, alcohol
- CT/ MRI Imaging: suggests vascular disease - shows cerebrovascular lesion
- Treatment:
-
Modify RFs
-
Statins, diabetes control, HT control, anti platelet
- Do not use acetylcholinesterase inhibitors or memantine in these patients.
-
Statins, diabetes control, HT control, anti platelet
-
Modify RFs
