Frailty- core conditions 3

Question 1

The Rockwood clinical frailty score 1-3

Answer 1

1 Very fit- people who are robust, active, energetic and motivated. Exercise regularly, among the fittest for their age
2. Well- people who have no active disease symptoms but are less fit than category 1. Often they exercise or are very active occasionally
3. Managing well- people whose medical problems are well controlled but are not regularly active beyond routine walking

Question 2

The Rockwood clinical frailty score 4-6

Answer 2

4. Vulnerable- Whilst not dependent on others for daily help, often symptoms limit activities. A common complaint is being ‘slowed up,’ and/or being tired during the da
5. Mildly frail- often have more evident slowing, need help with ADL. Typically mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework
6. Moderatly frail- people who need help with all outside activities and with keeping house. Often have problems with stairs and need help whilst bathing and need minimal assistance with dressing

Question 3

The Rockwood clinical frailty score 7-9

Answer 3

7. Severely frail- completely dependent for personal care from whatever cause (physical or cognitive). May seem stable and not at high risk of dying (within 6 months)
8. Very severely frail- completely dependent, approaching the end of life. Typically they cant recover even from a minor illness
9. Terminally ill- approaching the end of life. This category applies to people with a life expectancy <6 months who are not otherwise evidently frail

Question 4

PRISMA 7-a score of three or more indicates frailty

Answer 4

• Are you older than 85 years old
• Male?
• In general do you have any health problems that require you to limit your activities
• Do you need someone to help you on a regular basis
• In general do you have any health problems that require you to stay at home
• In case of need can you count on someone close to you?
• Do you regularly use a stick, walker or wheelchair to get about

Question 5

Frailty- walking speed

Answer 5

In order to identify frailty you can measure their walking speed. A slow walking speed is less than 0.8m/s or taking more then 5 seconds to walk 4m. Having a slow walking speed does not necessarily mean you are frail though.

Question 6

Comprehensive geriatric assessment

Answer 6

• Generates an individual problem list in the following areas: physical assessment, functional, social and environment assessment, psychological component and medications review
• Determines the needs of older patients with frailty and what interventions are required

Question 7

Multi-dimensional model of frailty

Answer 7

Frailty is a collection of modifiable health and social needs. For the individual with frailty it goes beyond physical health and includes psychological, social and physical domains

Question 8

The frailty fulcrum

Answer 8

Helps us think about frailty in a wider, holistic way. It is keeping vulnerability and resilience in balance, to limit effect on quality of life. If things change gradually we can make adjustments to try and increase resilience or decrease vulnerability to counterbalance changes, however if there is a sudden shift then patients are at much bigger risk of a destabilising life event

Question 9

Factors involved in the multi-dimensional model of frailty

Answer 9

• Systems of care- health and care staff, can be part of the social environment in hospital
• Acute health events- such as a stroke or fall, need effective management
• Physical environment- home environment
• Social environment- family members can be a source of resilience
• Psychological status- anxiety and depression
• Multimorbidity (long term conditions)- can be reduced through good management

Question 10

Delirium

Answer 10

• Seeming ’muddled’ not ‘usual self’
• Acute confusion: delirium, dementia, depression or combination
• Drowsiness and disorientation (time, place or person)
• May be agitated and irritable or quiet and withdrawn
• Identify and manage possible underlysing causes
• Reassure and re-orientate

Question 11

Falls

Answer 11

• ‘Found on the floor’- legs gave away
• Collapse, faint or slips/trips
• Complication of long period on the floor
• Look for multiple injury sites
• Consider impact of medication

Question 12

Incontinence

Answer 12

• Having ‘accidents’
• New onset or worsening condition
• May affect bladder, bowel or both
• Risk from over diagnosis of UTI, inappropriate antibiotics and diarrhpea
• Consider skin integrity and effects of catheterisation

Question 13

Immobility

Answer 13

• ‘Stuck in toilet’ ‘Slept in chair’
• Sudden change in mobility
• ‘Off legs’ can hide many diagnoses
• Comprehensive assessment to focus on urgent and important issue

Question 14

Medication side effects

Answer 14

• Greater susceptibility due to polypharmacy/4+ medications
• Wide range of symptoms and interactions with other symptoms
• Ensure availability of time critical medications
• Consider opportunities for deprescribing

Question 15

Managing frailty

Answer 15

• Complete a full geriatric assessment
• Ensure reversible medical conditions are considered and addressed
• Refer to geriatric medicine
• Old age psychiatry should be considered for frailty and complex co-existing psychiatric problems like challenging behaviour in dementia
• Personalised medication review- using evidence based criteria
• Consider a personalised shared care and support plan (CSP) which documents treatment and management plans. Ensure the CSP is shared between healthcare teams

Question 16

Essential skin lesions

Answer 16

• Epidermal (keratinocyte- derived)- non pigmented
• Melanocytic- tend to be pigmented

Question 17

Epidermal lesions- 4 basic tumours

Answer 17

• Basal cell papilloma- seborrheic keratosis, benign basal cancer. The most common skin tumour (Seb K)
• Basal cell carcinoma- malignant basal tumours (BCC)
• Solar/actinic keratosis- benign squamous tumour, caused by sun damage (AK)
• Squamous cell carcinoma- malignant squamous cancer (SCC)

Question 18

Layers of the skin and keratinisation

Answer 18

Basal cells are the top layer of skin, the squamous cells are below it and produce keratin. Abnormal keratin feels rough. Squamous tumours cause abnormal keratinisation or scaling on the surface

Question 19

Seborrheic keratosis

Answer 19

Appear to be stuck onto the skin. Pigmented as it has received more melanin from the melanocytes. Wart like appearance, with hills and channels on the surface of the wart. Contains small cysts of keratin which can be lighter or darker. Variable pigmentation. Only grows upwards, does not try and invade the body

Question 20

Basal cell carcinoma

Answer 20

Grows downwards as it tries to spread through the body. The growths remain attached to the tumour which first formed. As the islands grow downwards it squeezes the blood vessels meaning it is an avascular tumour. The tumours appear pale and translucent as they are lacking blood. Pearly looking. Larger blood vessels begin to grow so you see branching blood vessels on the surface (Telangiectasia)

Question 21

Erodent ulcer

Answer 21

A more advanced form of basal cell carcinoma, almost never metastasises but is locally invasive and slow growing

Question 22

Solar/Actinic keratosis

Answer 22

Dysplasia within the epidermis, have yet to invade and become cancerous. Has a hard, spiky scale can feel like sandpaper or bits of grit stuck to the skin. Produce abnormal keratin. Most common in areas of maximum sun exposure such as the back of the hand, bald scalp, temple, tops of ears and lower lip. An AK horn can form

Question 23

Bowens disease- Actinic keratosis

Answer 23

A red scaly plaque. When the epidermal cells are very dysplastic they forget to produce keratin. Full thickness epidermic dysplasia. Look like psoriasis, don’t have much of a scale

Question 24

Cutaneous horn

Answer 24

From squamous cells, shows that the lesion has become malignant

Question 25

Squamous cell carcinoma

Answer 25

When one cell from the Actinic keratosis has invaded and started to divide. Can metastasise unlike BCC. Appears as a lump with the SCC cells invading with a horn on top of it. Can occur quickly, if the lesion has formed within 3 months its likely to be SCC.

Question 26

Poorly differentiated SCC

Answer 26

No keratin is produced, looks like a BCC i.e. just a translucent lump. Has poor blood supply and often ulcerates, has rolled border

Question 27

Essetial lesions

Answer 27

* Epidermal derived: Seb K, AK, BCC, SCC * Melanocytic: malignant melanoma

Question 28

Malignant melanoma

Answer 28

* High mortality * Risk factors: fair skin, bad skin burns, lots of moles, high sun exposure * New moles in older people are likely to be melanomas * The main factor for prognosis is Breslow thickness, thicker tumours have worse prognosis * Larger then a normal mole, black colour, abnormal symmetry of the lesion *Anything that stands out against the patients other moles is worrying

Question 29

Difference between a lesion and a mole

Answer 29

A lesion is one abnormality in one area of the skin. A rash is more widespread and affects multiple area

Question 30

Different skin lesions

Answer 30

* Little and flat: macule * Big and flat: patch * Little and raised: papule * Big and raised: nodule * Plaque: flat area with a raised surface * Small fluid filled lesion: vesicle * Large fluid filled lesion: bullae * A pus filled lesion: pustule

Question 31

Other physical signs of a rash

Answer 31

* Surface change: crust, scale * Thickness of skin: absence (erosion/ulcer/excoriation), thickened (hyperkeratosis/lichenification) * Colour changes: Purpura/Necrosis, Pigmentation (haemosiderin v melanin)

Question 32

Crust

Answer 32

* Dried serum- implies the lesion has been weeping * Orange/yellow colour * May be confused with keratin (usually white/yellow) * Always remove the crust to reveal underlying pathology * When crust forms on tumours, it means that area of the tumour is unviable and necrotic

Question 33

Scale

Answer 33

* Abnormal stratum corneum * Accumulation of abnormal keratin * ‘Hyperkeratotic’- accumulates into large mounds * Can feel dry and flaky

Question 34

Thickened skin

Answer 34

Epidermal- Lichenification and warty processes, can be due to scratching of the skin. Normally occurs in eczema causes hills and valleys in the skin

Question 35

Rash- Missing skin

Answer 35

* Erosion- shallow loss of skin, restricted to the epidermis. The dermis is producing exudate which is forming a crust * Ulcer- all the epidermis and certain parts of the dermis and subcutaneous tissue is lost * Excoriation- patient scratching at their own skin

Question 36

Rash- colour

Answer 36

* Blood leakage- purpura (non-blanching)- dusky purple * Viability- necrosis- green -> black * Pigment- pale brown -> blue/black

Question 37

Palpable painful purpura- cutaneous vasculitis

Answer 37

Inflammatory process which affects the blood vessels which then die and leak blood into the surrounding area. Non blanching rash. Lesions are often painful and palpable.

Question 38

Cutaneous vasculitis progression

Answer 38

Purpura and necrosis. You get a lack of blood supply to the surrounding areas causing necrosis. Necrosis: green/black necrotic tissue is often seen in ulcers i.e. pressure sores.

Question 39

Rah- pigmentation

Answer 39

* Haemosiderin: yellow/brown, formed from blood breakdown * Melanin: depth of pigment alters colour, when its deep it appears blue

Question 40

Patterns of rash

Answer 40

* Symmetry: if its symmetrical there is more likely to be an internal cause i.e. psoriasis or eczema. If its not it may be due to an external cause i.e. bacterial cellulitus * Some patterns suggest certain diseases: Psoriasis extensor, Eczema flexural, Contact sensitivity, Photo distribution (seen in connective tissue diseases such as lupus)

Question 41

What is a rash

Answer 41

A rash is a change that appears on the skin, it is usually widespread, red and pimply. Pathology- under the epidermis, the lymphocytes have infiltrated the skin and are raising it up to form a pimple. Extracellular substances (like mucus in graves disease) can also infiltrate the skin causing it to be raised. What cells infiltrate the skin: lymphocytes, Eosinophils and Neutrophils.

Question 42

What are the main patterns of rashes

Answer 42

* Epidermal: Eczematous, Psoriasiform, Lichenoid, Vesiculobullous/blistering * Dermal: Vasculopathic, Granulomatous, tissue deposition

Question 43

Eczemarous and Psoriasiform rash

Answer 43

Eczematous: tiny vesicles or blisters form in the dermis. Little bits of keratin break off which we interpret as dryness. Weeping also occurs Psoriasiform: vast thickening of the epithelium, feels thicker and rougher as the keratin forms abnormally. Scale is the main feature of untreated psoriasis.

Question 44

Lichenoid and vesiculobullous rash

Answer 44

Lichenoid: also autoimmune destruction of the bottom layer of the epidermis. Often appear purple. Lots of the dermis gets replaced by lymphocytes and infiltrating into the epidermis and killing the epidermal cells to form colloid bodies Vesiculobullous: blistering rash. The epidermis separates from the dermis forming sub-epidermal blisters. Subepidermal blisters are tense and do not rupture easily

Question 45

Vasculopathic and Granulomatous rash

Answer 45

Vasculopathic: dermal rash, due to blood vessels becoming damaged and leaking can leak blood or fluid causing oedema. Smooth plaques form (urticaria) Granulomatous: attempts to wall of an area from the surrounding body. Formed from histocytes and lymphocytes. The collagen then degenerates. Often look orangey brown

Question 46

Tissue deposition

Answer 46

Scarring and thickening of the dermis. The collagen proliferates, has a waxy feel to it

Question 47

The main patterns of rashes

Answer 47

* Epidermal: Eczematous, Psoriasiform, Lichenoid, Vesiculobullous/blistering * Dermal: Vasculopathy, Granulomatous, Tissue deposition

Question 48

Rash's- in an autoimmune disease

Answer 48

You often get vasculopathic or Lichenoid changes. A purple rash in a light exposed area should make you think of lupus. Purpuritic areas show where the blood vessels have died

Question 49

Cellulitis

Answer 49

* Bacterial infection of the lower dermis and subcutaneous tissue * Red, painful, swollen skin with poorly defined edge * Usually unilateral * Can be associated with systemic symptoms * Commonly causes by strep pyogenes and staph aureus * Risk factors i.e. previous episodes of cellulitis, diabetes, venous disease etc

Question 50

Erysipelas

Answer 50

* Affects upper dermis * Usually caused by Group A beta haemolytic strep (Strep pyogenes) * Affected skin has sharp raised border (cellulitis less well demarcated, and does not have such marked swelling) * Red, firm and swollen * Treatment – penicillin antibiotic of first choice

Question 51

Treatment for skin infections

Answer 51

* Look for portal of entry * Swabs +/- bloods * Analgesia, fluid, elevation * Treat co-existing skin conditions * Uncomplicated cellulitis can be treated with oral antibiotics * If severe cellulitis or systemic symptoms, IV antibiotics are needed * Antibiotics based on local protocol or sensitivities * Prolonged course may be required

Question 52

Impetigo

Answer 52

* Superficial bacterial skin infection * Pustules and honey-coloured crusted erosions * Most often caused by Staph aureus, also caused by group A strep (Strep pyogenes) * Most common in children * Usually affecting face and hands * Single or multiple irregular crops * Bullous vs non-bullous - bullous due to Staph exfoliative toxins

Question 53

Boil- furuncle

Answer 53

* Staph aureus * May be associated with cellulitus * 10-20% of us are staph carriers- in the nose, axillae or groin * Treatment is topical antiseptic and oral antibiotics

Question 54

Meningococcal rash

Answer 54

* Neisseria meningitidis * Spreads via blood to brain causing meningococcal meningitis * Petechia and purpura, may be extensive * Ix-blood culture and LP * Rx-Penicillin