Elderly Medicine Flashcards
(78 cards)
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
How is dementia diagnosed?
* **History** from the patient with a thorough collateral narrative:
* **Timeline of decline and domains affected**
* **Activities of daily living**
* **Cognitive assessment:**
* **V**alidated 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
What is Alzheimers disease?
Who does it affect?
How does it present?
* 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
What is the cause or pathophysiology of Alzheimers?
**APP** (amyloid precursor protein) degradation
↓
**B amyloid peptide accumulation** in neurones
↓
Neuronal damage + **neurofibrillary tangles**
↓
**↓ ACh neurotransmitter ↓**
28
What are the sx of Alzheimers?
* **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
What are the RFs for Alzheimers?
* 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
How is Alzheimers managed?
* 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
What is vascular dementia?
* **Second** most common
* **Chronic progressive disease** causing cognitive impairment.
* Cumulative effect of **many small stroke**s: 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.
32
What is Lewy Body dementia ?
* **Gradually progressive**
* Presents:
* Auditory and visual **hallucinations**.
* **Delusions** are well formed and persistent.
* **Cognitive fluctuations** in cognition, attention, and arousal
* **Motor sx:** bradykinesia +/- rest tremor, rigidity, or both
* Dementia first, **parkinsonism later** (Parkinsons is the other way round)
* Histology: **Lewy bodies (alpha synuclein) in substantia nigra** in brainstem and neocortex.
* **Management:**
* **Avoid using antipsychotics** in Lewy body dementia (↑↑risk of SE) - e.g. **haloperidol**
* **Short acting benzodiapines: lorazepam**
* **Anti cholinesterase inhibitors:** donepazil
* Atypical anti psychotics: **quitiepine**
* **If w depression: give SSRI: sertraline**
* **Motor sx:** carbidopa/levodopa
33
What is frontotemporal dementia?
* **Early onset**
* Presentation:
* Complex behaviour, language dysfunction possible
* Coarsening of personality, social behaviour, and habits
* Behavioural/personality change; **disinhibition**; hyperorality, stereotyped behaviour, and emotional unconcern.
* Progressive loss of language fluency or comprehension
* Development of memory impairment, disorientation, or apraxias
* **Diagnostic fx:**
* **Age of onset: peak mid 50s**
* FH of FTD
* Altered eating habits
* **Imaging: Frontal and temporal atrophy:** loss of \>70% of **spindle neurons**.
* **Pick** i**nclusion bodies** on histology
* Management:
* Supportive
* If irritable: Anti psychotics: 1: lorazepam, 2, haloperidol
* SSRIs: sertraline
*
34
What are the types of incontinence?
* Stress incontinence
* Urge incontinence
* Overflow incontinence
* Functional incontinence
* Mixed incontinence
35
What is stress incontinence?
* RFs: Increasing age, obesity, women
* Small volumes leak out during increased intra abdominal pressure
* Common in pregnancy and following birth
* Examine for pelvic floor weakness/prolapse/pelvic masses
* Management:
* Pelvic floor exercises, exercise, weight loss
* Duloxetine
* Tension free vag tape
36
What is urge incontinence?
* **Frequent voiding**
* **Cannot hold urine**
* Urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts
* **Nocturnal incontinence** common
* Overactive bladder: **Detrusor overactivity**
* Management:
* Conservative: bladder retraining, fluid moderation, avoid caffeine
* Pharm: Antimuscarinics:
* **1st: oxybutinin, tolterodine sr 4mg/24h;**
* **2nd: solifenacil**
* Surgery: neuromodulation, sacral stimulation
37
What is over flow incontinence?
* Due to urinary retention
* Obstructive symptoms
* Often found in men with enlarged prostate
38
What is functional incontinence?
* When physiological factors are relatively unimportant.
* The patient is ‘caught short’ and too slow in finding the toilet because of (for example) immobility, or unfamiliar surroundings.
39
What should a continence history focus on?
* How people void
* Frequency
* Symptoms
* Oral intake
* Types of drinks consumed
* Bowel habit - stool type + frequency
* Drug history
40
What is covered in a continence history?
* Review of bladder and bowel diary
* Abdo exam
* Urine dipstick + MSU
* PR examination - *prostate* exam in male
* External genitalia - *atrophic vaginitis* in women
* Post micturition bladder scan
41
How is urge incontinence managed?
* **Conservative**: Avoid caffeine, good bowel habit, Improving oral intake, regular toileting and pelvic floor exercise, bladder retraining
* **Pharmacological**: Anticholinergics
1. **Oxybutinin** - young people
2. **Tolteridine** - not for old ppl -\> causes postural hypotension or **solefenacil**
* **Surgery: botox/** neuromodulator or sacral stimulation
42
How do you manage bladder incontinence?
* **Stress incontinence: duloxetine** 40mg / 12hr PO (se: nausea)
* **Urge: Anticholinergics** -
1. **Oxybutinin** - young people
2. **Tolterdine** - not for old ppl -\> causes postural hypotension or **solefenacil**
43
Why are the elderly prone to faecal incontinence?
* Rectum becomes more vacous as we age
* External anal sphincter can gape (haeamarrhoids, constipation)
* Old people cannot exert the same intra abdominal pressure and muscle tension required to defaecate
44
What should you be concerned about with faecal incontinence?
Spinal cord pathology - urgent management required
45
What is the most common cause of faecal incontinence?
* **Faecal impaction with out flow diarrhoea** (50%)
* 2nd: neurological dysfunction
46
How is faecal incontinence diagnosed?
PR exam
47
What should we assess in the PR exam?
* Rectum
* Prostate (men)
* Anal tone
* Sensation
* Visual inspection around anus
* Stool type (soft, hard)
48
If you find faecal/ urinary incontinence what must you do?
Check for the other
If you find urinary, check for faecal etc
49
What are some of the more extreme complications of faecal impaction?
* Stercoral perforation
* Ischaemic bowel
50
How are hard impacted stools managed?
* **Enemas**: some may not work if the rectum is loaded with hard stool and will fall out
* **Stool softeners**
* **Stimulants**
* Extreme cases: **manual evacuation (**risk of perforation)
* In older pt make sure any drug that causes constipation as a SE is prescribed with a laxative?
51
How is chronic diarrhoea managed in the elderly?
* Treat underlying causes: bowel imaging, stool culture
* **Remove causative medications**
* Regular toileting
* Low dose **loperamide**
* **Eneme regimines**
52
What is a TIA?
* Focal neurological deficits due to a blockage of a blood supply to a part of the brain
* Symptoms lasting \<24h
53
What are some of the signs of TIA?
* Specific to the arterial territory involved
* *Amaurosis fugax* - when retinal artery is occluded
* Global events (eg syncope, dizziness) are not typical
54
What are some of the causes of TIAs?
* **Atherothromboembolism** from the carotid: listen for bruits
* **Cardioembolism**: mural thrombus post-mi or in af, valve disease, prosthetic valve
* **Hyperviscosity:** eg polycythaemia, sickle-cell anaemia, myeloma.
55
What investigations are required for TIA diagnosis?
* fbc, esr, u&es, glucose, lipids, cxr, ecg,
* **Carotid Dopple**r ± **angiography**
* **CT/ MRI**
* Echocardiogram.
56
What are some of the sx of stroke?
* Unilateral weakness or parlaysis
* Aphasia
* Ataxia
* Dysphagia
* Diplopia
* Vision loss
57
What treatment is given for TIAs?
* **Control cardiovascular risk factors:** bp; hyperlipidaemia, stop smoking
* **Antiplatelet drugs:** **aspirin 300mg od for 2wks**, then switch to clopidogrel 75mg od
* **Carotid endarterectomy:** Perform within 2wks of first presentation if 70–99% stenosis
* *Give anticoagulants if cardiac emboli caused it*
58
What is used to predict the short term risk of TIA -\> progressing to stroke?
* **ABCD2**
* **Look at the following factors:** age, BP, clinical features, duration of sx, diabetes)
* =\>4 - Higher risk
* =\>6 - Strongly predicts stroke
59
What is a stroke?
* **Infarction** or **bleeding** into the brain manifests with **sudden-onset neurological deficit**
* Sx \>24 hours
60
How are strokes broadly caused?
1. Infarct
2. Haemmorhage
61
How are strokes classified?
* **Bamford Classification** - *Haemmorhagic* - Classifies vascular territory involved
* **TOAST classification** - *Ischaemic* - aetiology of infarcts
*
62
What are the causes of stroke?
* **Small vessel occlusion/cerebral microangiopathy or thrombosis** in situ.
* **Cardiac emboli**
* **Atherothromboembolism** (eg from carotids)
* **CNS bleeds:** ↑bp, trauma, aneurysm rupture, anticoagulation, thrombolysis
63
What are the modifiable RFs of stroke?
↑bp, smoking, dm, heart disease (valvular, ischaemic, af), peripheral vascular disease, ↑pcv, carotid bruit, combined ocp, ↑lipids, ↑alcohol use, ↑clotting (eg ↑plasma fibrinogen, ↑antithrombin iii, p[link]), ↑homocysteine, syphilis.
64
How are strokes acutely treated pharmacologically?
* Thrombolysis: As soon as haemorrhage has been excluded, symptoms must be ≤4.5h ago: **Alteplase**
* **CT 24h post-lysis** to identify bleeds
* Anticoagulants: **aspirin 300mg** (for 2 wks, then switch to long-term antithrombotic treatment,
65
How else do you manage a stroke (think non pharmacologically)?
Protect the airway:
Maintain homeostasis:
* **Blood glucose:** 4–11 mmol/L.
* **Blood pressure:** only treat if there is a hypertensive emergency (eg encephalopathy or aortic dissection)
* **Screen swallow:** ‘Nil by mouth’ until this is done (but keep hydrated).
* **CT/MRI within 1h:** Essential if: thrombolysis considered, high risk of haemorrhage (↓GCS, signs of ↑ICP, severe headache, meningism, progressive symptoms, bleeding tendency or anticoagulated), or unusual presentation (eg fluctuating consciousness, fever).
* **Diffusion-weighted MRI** is most sensitive for an acute infarct, but ct helps rule out primary haemorrhage
• **Haemorrhoagic stroke:** Antiplatelet agents: **aspirin 300mg** (continue for 2 weeks, then switch to long-term antithrombotic treatment)
* *Orally - is not dysphagic, enterally if yes*
• **Ischaemic stroke: Thrombolysis:** sx ≤4.5h ago.2 **Alteplase**. CT 24h post-lysis to identify bleeds
66
What are the different types of stroke?
* TACS - Total anterior circulation stroke - *worst prognosis*
* PACS - Partial anterior circulation stroke
* LAC - Lacunar stroke
* POCS - Posterior circulation stroke
67
What assessment tools are used for the rapid assessment of a pt with suspected stroke?
* **FAST -** Face (drooping), Arms (weakness), Speech (slurred), Time (time to call 999)
* **ROSIER -** Used to help medical staff distinguish between a stroke and a stroke mimic.
* **NIH stroke sale** - clinical stroke assessment - measures stroke severity. Scores on all levels of consciousnes, language, neglect, visual field loss. extra ocular movement, motor strength, ataxia, dysarthria, sensory loss.
68
What is the criteria for **carotid endoarterectomy**?
* **Carotid artery stenosis: 50-99%** with stable neurological symptoms from stroke / TIA
* **Refer within 1 week** of stroke or TIA symptoms sx
* Assess **fitness for surgery** (risk of stroke in surgery)
69
What is one of the risks of severe MCA infarction?
**Malignant MCA syndrome**
* Consider for **decompressive hemicraniectomy**
* Referred within 24 hrs of sx onset and treated withn 48hrs
* \<60 yo, CT infarct of at least 50% MCA territory and **NIHSS \> 15 hours**
70
What are some of the stroke mimics?
* Seizures
* Space occupying lesions
* Hemiplegic migraine
* Multiple Sclerosis
* Sepsis
* Pre neurological weakness
71
How do you decide if someone is suitable for anti coagulation?
* **CHAD-VASC -** determining if someone is suitable for anticoagulation - AF + risk of stoke
* **HASBLED**
*Warfarin vs DOAC*
72
Post stroke, what other complex decisions need to be decided?
* DNAR
* NG and PEG
* Enteral feed - without risk
* Aspirational threat
73
How is palliative care now provided?
* Previously Liverpool Care Pathway but this is no longer used
* Care is now individualised for each patient.
74
How can end of life phases be recognised:
* Bed bound
* Semi comatose
* Only takes sips of fluid
* Unable to take mediine orally
* Sx: pain, nausea. vomiting, dyspneao, agitation, confusion, constpitation, anorexia, terminal secretion
75
What should we continue to provide for end of life care
* Personal care
* Obs stopped
* Dental and mouth care
* Macmillan nurses and palliative care team
76
When is a death certificate given?
* To be completed by doctor that has cared for pt in last 14 days to complete death certificate
* Pupils: fixed and dilated
* No response to pain
* No breath/ heart sounds after 1 min of auscultation
* Pt transported tm mortuary and bereavement
77
Who is cremation paperwork completed by ?
* Two doctors
* **Part 1** - Completed by a doctor who knows the pt
* **Part 2** - **Independent doctor.** 2 years post reg. Seeking confirmation of the cause of death from a variety of course
* *Remember: pacemarkers and radiactive implants must be removed before cremation*
78
When should a death be reported to a coroner?
* Occurs as a result of poisoning
* Trauma, violence and physical injury
* Related to treatment or procedure
* Injury or disease received during or attributed to persons work
* Notifiable accident, poisoning or disease
* Neglect or failure
* Unnatural death
* Death occured in custody
* No attending practitioner attended decreased within 14days prior
* Unknown identify
