General Aged Care Flashcards
(145 cards)
1
Q
how might we assess an elderly patient’s mobility?
A
TUG- timed up and go
the 6 minute Walk Test
2
Q
what is happening structurally as the bladder stores urine?
A
bladder relaxation and internal + external urinary sphincter contraction
3
Q
what examinations would you perform in an elderly patient who presents with a fall?
A
• Neurological examination- assessing for balance, coordination, gait, peipheral neuropathy
• Joint examination
• Visual acuity
• Postural hypotension- take the blood pressure
• Examine injured limb
• Look for mobility aids, glasses
• Look for deformities like kyphosis or lordosis
• Romberg’s test looking for impaired proprioreception
Dynamic and static balance testing with physiotherapist
-examine their footwear!
MMSE/RUDAs
4
Q
describe the two micturition stages (storage and voiding) and the nerve fibres associated with it
A
storage of urine- hypogastric nerve sympathetically innervates detruser muscle relaxation and internal urinary sphincter contraction (via noradrenaline acting on alpha 1 receptors at bladder neck, and at beta adrenoreceptors in detruser muscle). Sympathetic nerve fibres inhibit parasympathetic nerve stimulation. Uninhibited somatic fibres in pudendal nerve release AcH on nicotinic receptors causing contraction of the external urethral sphincter.
As the bladder fills, stretch receptors increase afferent firing rates and is perceived by the CNS system
voluntary voiding- inhibition of the pudendal somatic nerve fibres (as directed by CNS) cause relaxation of the external urinary sphincter.
Parasympathetic fibres from the pelvic nerve coordinate bladder contraction and internal urinary sphincter relaxation–> voiding
5
Q
what are some rehabilitation goals for patients following a stroke?
How might we achieve them?
A
- prevent complications e.g. PE/malnutrition/pressure sores/contractures etc
- optimise mobility
- optimise PADLs
- home visit by OT
- Assess driving capacity
- management of communication deficits e.g. dysarthria, aphasia
- application for community services e.g. meals on wheels, cleaning services etc
- provide education and support for carers/family
Multimodal approach requiring various allied health staff including OT, speech pathologist, physio, social worker and nursing staff. We can use splinting and certain positioning to prevent contractures (nursing) etc, we can practice progressive resistance exercises + strengthening exercises (physio), we can practice functional tasks such as cooking and use compensatory techniques such as altered cutlery (OT), we can seek extra community support services (social worker) for example.
6
Q
what are the 5 elements of dementia?
A
- cognitive impairment
- chronic condition
- acquired condition
- change from previous level
- impact on function
7
Q
what does an occupational therapist do?
A
they can assess cognition, functional assessment (ADLs/PADLs/CADLs), home + environment assessment
8
Q
what extrinsic factor for falls in the elderly must we exclude?
A
polypharmacy- warrants medication review
consider anti-depressants, benzodiazepines, anti-hypertensives, digoxin and opioid medications
9
Q
what are some treatments for dementia?
A
No curative treatment available, management is rather supportive in nature.
Anti-cholinesterase medications such as donezepil, rivastigmine can be used in mild-moderate AD. Only provides very slight cognitive benefit.
Memantine, an NMDA r antagonist can be used in moderate-severe AD. Again, clinical efficacy is limited.
adjuvant medications for psychotic symptoms/depression/anxiety etc
10
Q
hallmark features of lewy body dementia?
A
- visual hallucinations
- fluctuating course- can vary from day to day and can mimic delirium
- parkinsonian features
- late onset memory loss
11
Q
what are some bad prognostic factors for rehabilitation after stroke?
A
- difficulty isolating any movement in affected limb
- receptive dysphasia
- visual neglect/hemianopia
- urinary + faecal incontinence
12
Q
who benefits from a CGA?
A
elderly patients with moderate disability
13
Q
what RUDAs score suggests possible cognitive impairment?
A
RUDAs score equal to or less than 22 out of 30
14
Q
what is fried’s criteria for frailty?
A
1 unintentional weight loss 2 slow walking speed 3 weakness 4 exhaustion 5 low physical activity
greater than 3= frailty
15
Q
what is senakot and its usual dosing?
A
senna (bowel stimulant) twice a day
16
Q
list the hip precautions post THR?
A
No hip adduction across the midline
No hip flexion beyond 90 degrees
No internal rotation of the hip
Caution when squatting or sitting
no driving for 6 weeks
hip precautions generally for 3 months post op
17
Q
what is the risk assessment component of a CGA?
A
screening for falls risk (FRAT tool)
screening for risk of pressure sores (skin integrity scale)
18
Q
risk factors for dementia?
A
age education level genetics (think AD) head injury cerebrovascular disease- e.g. obesity/diabetes/HT depression
19
Q
what assessment tools can we use to assess an elderly patient’s functional independence (e.g. ADLS/PADLs etc)?
A
FIM- functional independence measure
Barthel index
20
Q
how might constipation cause urinary incontinence?
A
- weakened detrusor muscles due to straining
2. impacted rectum may compress the bladder- leading to the sensation that the bladder is full
21
Q
what parts of the CNS are involved in the micturition reflex?
A
pons
PAG
spinal cord
22
Q
what happens to the bladder during micturition?
A
external urinary sphincter relaxes
bladder (detruser muscles) contracts
23
Q
ddx for dementia?
A
delirium, depression, mild/moderate intellectual disability, drugs
24
Q
side effects of cholinesterase inhibitors
A
GI disturbances (N+V, anorexia), vivid dreams, low heart rate, dizziness
25
describe fronto-temporal dementia?
early behavioural changes
executive dysfunction
language disturbance
there may be an associated family history
new learning is preserved until later stages
26
functions of frontal lobes
1. inhibitory signals
2. planning and organisation (anteriolateral side- most important function)
3. motivator
27
what are some less common causes of dementia?
alcohol, HD, hydrocephalus, hypothyroidism, B12 deficiency, neurosyphilis
28
what is a normal residual bladder volume?
less than 50mls, but if they are older you can accept up to 100mls
29
components of CGA
medical history
functional ability
cognitive and psychological function
socioenviromental circumstances
30
define dementia
acquired chronic decline in high mental functioning that results in significant cognitive and social impairment
31
what is macrogol?
movicol- bulking agent for constipation
32
what does contained incontinence mean?
despite all the modifications/meds used, incontinence still occurs. So we just need to manage it (contain it) using pads etc
33
what do we mean by 'cognitive impairment' in dementia?
```
problems with:
memory
aphasia
apraxia
agnosia
```
34
what are the types of urinary incontinence?
stress
urge
overflow
mixed
35
what are some factors that determines a patient's suitability for rehabilitation?
- medical stability
- cognition status
- level of motivation
- availability of supportive family/carers/environment
- reasonable timeframe?
36
if non-pharmacological and pharmacological methods for urge urinary incontinence fail, what can we do next?
what risks are involved?
intra-detruser botox injection
risk of self-catheterisation 10% of patients
37
what does a social worker do in terms of rehab?
assesses finances, social situation, living arrangements etc
38
what cognitive dysfunctions are seen in AD
learning abilities
memory/amnesia
apraxia
language difficulty
39
what does MMSE miss out on?
does not test frontal lobe function
40
what does dependent continence mean?
patient is continent if uses meds/behavioural modifications etc
41
what drugs can cause confusion?
levodopa/other parkinsonian drugs, steroids, anti-cholinergics, antibiotics, opioids
42
what are some ix you will order for an elderly patient who presents with a fall?
```
ECG
DEXA scan
Fingerprick glucose
Urine drug screen
x-ray if suspect fracture
B12, folate, FBE/UEC/lipids etc
vitamin D, CMP levels
```
43
a female patient presents with complaints of urinary incontinence. what are the key things to look for on examination?
All women presenting with incontinence need a pelvic examination with special attention to evaluate for vaginal atrophy, pelvic masses, and pelvic organ prolapse
+/- neuro exam
44
what drugs exacerbate urinary incontinence symptoms and why?
1. hypnotics e.g. temazepam- will slow arousal and make it difficult to get to the toilet quickly
2. ace inhibitors- chronic cough--> increased abdominal pressure
3. calcium channel blockers e.g. verapamil--> constipation--> incontinence
4. caffeine/alcohol--> direct bladder stimulant + diuretic
5. alpha blockers- reduce outflow resistance--> exacerbates stress incontinence
45
what do we mean by 'hot falls'
acutely unwell but present with a fall as a nonspecific marker of ill health
46
how do we test praxia?
ask the patient to copy drawing/diagrams
47
what are some causes of urinary incontinence that we cannot miss?
• Spinal cord compression
• MS
• Stroke
Diabetes
48
RUDAs stands for?
| and how is it different from MMSE?
rowland universal dementia assessment scale
can cater for non-english speaking patients (bridges language barrier) and also tests some executive function
49
how do we choose patients for CGA?
opportunistic screening in hospital
GP referral to ACAS
50
describe the TUG test
timed up and go
patient needs to get up from chair, walk 3 m from chair and then back to the chair. Sit back in chair.
measured in secs and patient allowed normal gait aids.
Normal is less than 10secs
51
how might we manage urge incontinence?
Fluid restrict to 1.5L, avoid ETOH/caffeine, weight loss, bladder retraining with physiotherapy;
pharmacotherapy= anti-cholinergics- e.g. oxybutyrin, vaginal oestrogen (if atrophic vaginitis), TCA, beta 3 agonist (mirabegron)
botox injection for detruser muscles
referral to continence clinic/nurse
52
protective factors for dementia?
education
physical activity
social engagement
cognitive engagement
53
what ix do we need to consider in a CGA for an elderly patient?
there are no routine investigations.
test as indicated
54
what is a mechanical fall?
Falls due to major external factors
55
how might we assess an elderly patient's nutrition?
mini nutritional assessment MNA
56
what nervous systems control the micturition reflex?
sympathetic T10-L2 (storage of urine)
parasympathetic S2-4 (voiding)
somatic S2-4 (voluntary voiding)
57
tell me about GDS?
geriatric depression screen
yes or no questionnaire, out of 15
>5 is suggestive of depression
58
risk factors for AD?
increasing age, down syndrome (extra chromosome 21= more APP), genetic predisposition (apolipoprotein E4)
59
describe mirabegron and indication?
- beta3 agonist for urinary urge incontinence
- relaxes bladder muscles during storage phase of urine--> increased capacity
metabolised by the liver
may affect BP and HR so always check esp if the patient is on metoprolol and digoxin
60
what are some differentials for urinary incontinence in an elderly patient
```
• UTIs
• Faecal impaction
• Medications
• BPH
• Delirium
• Depression
• Dementia
Functional incontinence
```
61
define urinary incontinence?
the involuntary leakage of urine
62
what can a speech pathologist do?
they can assess and manage:
1. cognition (patient must be alert and awake before any assessment)
2. swallowing (history, swallow saliva?, tiny sip of water?, can they cough? going through the 4 phases of swallowing-)
3. speech
63
name some cholinesterase inhibitors?
donepezil, galantamine, rivastigmine
64
which tool do we use to look for delirium?
CAM tool and cognitive screen
65
commonest causes of dementia?
alzheimer's, vascular disease, frontal lobe dementia, lewy body dementia associated with Parkinson's
66
how might we investigate/examine fronto-temporal dementia?
frontal tests-verbal fluency, abstraction, alternating tasks
MMSE may be normal
Structural neuroimaging- brain atrophy and functional neuroimaging- decreased frontal perfusion
67
what do we mean by 'cold falls'
falls in generally frail older people with multiple contributory factors
68
describe what is usually happening in the bladder during urge incontinence
bladder overactivity (detruser muscle overactivity)
69
tell me what is the MMSE, and what are its disadvantages
MMSE was developed as a screening tool for Alzheimer's disease; doesn't screen frontal lobe issues + doesn't cater for non-English speakers
70
how might we address carer stress?
```
case manager
social worker
psychologist
employed carer
nursing home transition
respite care
```
71
define rehabilitation?
a multidisciplinary approach to help a patient maximise their fullest physical, psychological, social, and educational potential with their disability
72
describe vascular disease dementia
tends to present suddenly
patient deteriorates on step wise levels
focal neurological signs
infarction (white matter change) seen on radiology- hippocampus is usually not affected
73
how do we assess for 'alertness/attention' if suspecting delirium?
get the patient to count back from 20
74
what are the subtopics of the medical history of a comprehensive geriatric assessment that need to be addressed?
- medications + compliance + delivery method
- continence (urinary and faecal)
- cognition- memory and functional tasks
- falls- mechanism, predisposing factors etc
- mobility- gait aids, use of p.transport, independent/dependent
- pain
- nutrition- nutritional status
- living arrangements
- legal status- power of attorney, will, driving etc
- advanced care plan!
75
what do we need to exclude prior to commencing cholinesterase inhibitors?
bradycardia as the medication can cause heart block so do an ecg
76
what MMSE score corresponds to cognitive impairment?
generally less than 24/30
but for less than 27/30 you would still think mild cognitive impairment
77
how might we ix urinary incontinence?
- rule out UTI + glucouria (so dipstick, MSU)
- renal function, electrolytes, BSLs
- daily voiding/bladder diary showing fluid intake, output volumes etc
- post void residual volume measurement via bladder scanner
- urodynamics= gold standard for elderly patients
78
what are the key domains of the functional assessment part of the CGA?
PADLs, ADLs, CADLs
think cooking, cleaning, toileting, showering, walking, driving, shopping, banking, driving, medication administration
79
is topical oestrogen therapy for atrophic vaginitis safe?
generally safe as it is not systemically absorbed.
However, if there has been very recent breast cancer, this therapy is contraindicated.
80
investigations for suspected cognitive decline/change in general? (don't give me assessment tools like MMSE)
• CT brain (bleeds/infarcts/atrophy) +/- MRI
• Bloods- TFT/B12/folate/eGFR/electrolytes/BSL/FBE
-Urine test looking for infection (raised WCC etc)
81
what is nocturnal polyuria?
more than 1/3 of total daily urine production produced overnight (including first morning void)
82
what is CGA
comprehensive geriatric assessment
multidimensional process to determine the medical, psychological, functional capacity of elderly patient to develop an integrated plan for treatment and follow up
83
what is usually the cause of overflow incontinence? what are some other causes
detruser muscle underactivity
urinary outlet obstruction is another cause
84
how might we prevent future falls in an elderly patient? what are some options of management?
1. Refer to balance training/core stability exercises with physiotherapist or yoga/tai chi instructor.
2. Medication review- remove psychotropic medications if possible.
3. Address nutrition- encourage good nutrition with a referral to dietician. Important to have protein + vitamins.
4. Fix vitamin and mineral deficiency- vitamin D, and calcium supplementation as needed
5. OT review- environmental modifications in the home environment
6. Optometrist review + referral for cataract surgery if required
7. Advise correct use of gait aids, and also encourage behavioural changes including standing up slowly and not wearing high heels etc
8. Optimise other medical comorbidities such as diabetes (referral to podiatrist/endocrinologist as appropriate etc), cardiovascular risk factors, OSTEOPOROSIS
85
what are some non-pharmacological approaches to urinary incontinence in general?
pelvic floor exercises
environmental modifications e.g. commodes/urinary bottle nearby
avoid caffeine/alcohol/night time fluid intake
weight loss
fluid restriction
avoid constipation
optimise mobility- gait aids etc
86
what is atrophic vaginitis? and how to treat it?
what type of complications can it cause?
post menopausal reduction in oestrogen causes thinning of membranes + dryness which can cause a burning sensation similar to dysuria.
Treated with antifungal and barrier cream, + oestrogen topical therapy/plessary
Incontinence associated dermatitis--> nappy rash
87
what is the difference mild cognitive impairment between dementia? Describe MCI in general terms
MCI does not impact on function whereas dementia does
Objective cognitive impairment and change from normal functioning. Preserved overall general function but increased difficulty in ADLs. Usually presents as a complaint from the person or family member
88
what are some key questions that should be asked when assessing a patient's falls risk?
Circumstances of the fall
- Activity at time of fall
- Location
- Use of walking aid (carrying them or not) and footwear
- Time of day
- Lighting
- Use of eyewear (type, worn or not)
- Warning symptoms eg vertigo, palpitations
- Loss of consciousness
* Previous falls or near falls
* Observer history
* Fear of falling
* Impact on lifestyle (eg will no longer go outside alone)
* Injuries/complications
* Ability to get up following the fall
89
how can diabetes cause urinary incontinence?
autonomic neuropathy leads to overactive detruser muscles--> increased contractility and impaired emptying
residual bladder volume increases --> overflow incontinence
Eventually the detruser muscles will become acontractile--> urinary retention
90
what are some things to consider when assessing a patient's suitability for rehabilitation?
Is the patient medically stable?
Does the patient have reasonable cognition?
Do they have poor prognostic features e.g. paralysis/poor executive function
Are they relatively motivated to participate in rehabilitation?
Do they have supportive family/carers after discharge from rehab?
Will rehab increase their overall function?
91
what are some rehab goals for a pt who has just had a stroke and now is ready for rehab (i.e. medically stable enough)?
A structured rehab plan should be put in place. May require up to 6 months post stroke for adequate rehabilitation.
Goals for rehab should be outlined, considering patient's premorbid functioning/motivation and whether it is feasible within a structured time frame.
General stroke rehab goals include:
1. Improve mobility, reduce falls risk- PT
2. Improve communication (dysarthria/dysphagia)- speech path
3. improve nutrition- speech path + dietician
4. return to functioning (ADLs/PADLs) + modification of home environment
5. improve memory/cognition
6. management of psychological impact- psychologist
7. organise psychosocial support- social worker
8. prevent and manage complications such as incontinence, carer burden, deconditionng, pain. DVT/PE, falls risk as needed
92
hallmark features of alzheimer's dementia?
memory impairment esp episodic memory loss--> anterograde long term episodic amnesia
language impairment- esp word finding difficulty
apraxia (difficulty performing learned motor tasks)/visualspatial difficulties
93
which part of the brain is affected in AD?
Medial hippocampus- atrophy
| Temporal-parietal lobe- atrophy
94
what MoCa score indicates cognitive impairment?
25 or less
95
apart from performing the MMSE, what other ix/assessments can we order for AD?
MRI brain- looking for atrophy in hippocampus/temporal lobes, and to rule out other causes of cognitive decline
formal neuropsychology assessment
Bloods to exclude B12 deficiency or hypothyroidism
96
what are some preop considerations for major amputations?
1. Level of amputation- is there enough vascular arterial perfusion for adequate healing? is there enough structural integrity in the bones at this level?
2. prophylactic antibiotics
3. anticoagulation
4. early commencement of preop/postop pain management including anaesthesia to reduce risk of phantom limb pain
97
what are some causes of post operation pain in an amputated limb?
```
stump pain including ischaemic stump pain
neuroma pain
pressure point pain from bony spurs
Infection
phantom limb pain (dx of exclusion)
```
98
what are some post operative complications of amputation surgery?
```
contractures
DVT/PE
wound infection
MI
Pressure ulcers
Wound infection
Systemic infection
Stump haematoma
```
99
if you had a patient with BPSD from LBD that was showing signs of aggression, and was not responding to non-pharmacological methods, which drug would you go for?
quetiapine.
not risperidone/haloperidol/olanzapine due to EP side effects
100
what are some non-pharmacological ways of managing delirium?
```
protect airway
calm familiar environment
reduce external stimuli
maintain hydration + nutrition
avoid physical restraints including unnecessary canullas
let the family know
use simple instructions and avoid jargon
use orientating instruments such as clocks/calendars in room
Limit staff change if possible
```
101
what are the common SE of mirabegron?
Increased BP, nasopharyngitis, UTI
102
what are the examinations we need to perform in a woman presenting with urinary incontinence?
pelvic + abdomen examination, particularly looking for vaginal atrophy, pelvic masses or prolapse
neurological examination including gait, perianal sensation, power, tone and reflexes
103
what score on the geriatric depression scale indicates depression?
greater than 5
104
what are some causes of constipation in elderly patients?
drugs- opioids, calcium channel blockers, iron, anticholinergics
neurological disorders- MS, spinal cord compression etc
geriatric syndrome- immobility, cognitive decline, dehydration/poor nutrition, depression, other psych conditions
malignancy- bowel obstruction, metastases
endocrine cause- diabetes--> autonomic neuropathy, hypothyroidism
105
What are some typical characteristics of an elderly patient who is at high risk of suicide?
```
• Elderly male
• Living alone
• Personality dysfunction
• Alcohol abuse
• Recent bereavement
Physical illness/frailty
```
106
what are some anatomical brain changes that occur as we age?
loss of synaptic density
deterioration of myelin sheath
change in NT levels
107
What does CIND stand for
cognitively impaired not demented
108
what is the most common type of dementia in patients from asian heritage?
vascular dementia
109
On radiology, what is a characteristic feature of frontotemporal dementia?
knife edge sign
110
what can we use as biomarkers of AD?
PET/MRI changes
neuropsych assessment
Lumbar puncture
111
what are some issues to address for MCI?
* Disclosure of diagnosis
* Information on assessment results
* Pharmacological and non-pharmacological approaches (emphasise non-pharmacological approach)
* Monitoring of health and vascular risk factors
* Discuss ADLs including driving
* Planning the future (finances/travelling etc)
* Address Carer burden
* Information on useful contacts
Regular follow up appointments (e.g every 6 months or every yr)
112
a geriatric patient presents with late onset mania. what do you think?
organic cause unless proven otherwise
consider steroids/cognitive impairment/post surgical cx
113
when doing a MSE on a psychogeriatric patient, what are some key things you must include?
focus more on cognition using MMSE and clock drawing tool
elicit visual hallucinations and other hallucinations in other sensory modalities such as olfactory/somatic etc
always keep a look out for morbid jealousy delusions and command hallucinations
always look for signs of an organic cause
114
describe some general symptoms of BPSD?
```
agitation
psychosis
depression
mania
disinhibition
eating problems
abnormal or inappropriate vocalisations
```
115
describe the natural history of BPSD?
emerge --> worsen--> plateau--> improve --> vanish
116
in which stage of dementia do we usually see BPSD?
moderate- severe dementia
117
what is exelon?
rivastigmine
118
best pharmacological management option for BPSD?
olanzapine/risperidone
119
how might we prevent dementia?
no absolute preventative strategy but at the moment reducing cardiovascular risk factors such as midlife hypertension/obesity and smoking cessation have the best evidence --> reduces risk of cerebrovascular disease--> dementia
It also seems that that a higher level of education attained may also be a protective factor against dementia
120
who comprises of the team who looks after a geriatric patient with BPSD?
What types of settings/residences may be required for patients with BPSD?
geriatrician +/- old age psychiatrist- manages overall mx and medications
nurse- provides ongoing nursing care
social worker- liaises with family members and organises community support groups
psychologist- outlining a behavioural plan
Generally mild cases of BPSD can be managed in the community in residential facilities. As the BPSD symptoms become more severe and aggressive, you may consider referring to a psychogeriatric ward or a dementia focused nursing home. You would want a place where there is a high number of staff per patient because of security reasons.
121
how is memantine excreted?
renally cleared
122
what are some post op considerations for orthogeriatric surgery?
1. pain mx- PCA or other pain meds (watch out for SE in elderly patients including confusion/renal impairment)
2. anticoagulation- clexane; early mobilisation; A/c up to 4 weeks post op
3. screen for post op confusion- infection/drugs/withdrawal/electrolyte disturbances
4. mx wound healing and prevent other complications
123
what are some ix we can order for assessment of osteoporosis?
Dexascan - BMD
Vitamin D and calcium levels
TFTs, PTH
Beta-CTX, P1MP, ALP - bone turnover
Serum protein electrophoresis, free light chains, ESR (>100)
Coeliac antibodies
124
how might we address common deficits post stroke during rehabilitation such as dysphasia/dysarthria/aphasia, dysphagia, weakness/immobility, visual neglect/hemianopia and cognitive deficits?
Make references to the appropriate allied health member in your answer.
Communication- work with speech therapist who may suggest using non-verbal means such as gestures and drawings, or other communication aids.
Swallowing- work with speech therapist who may suggest fluid/diet modification, changes in position when eating, or some exercises to improve oral musculature strength
Weakness- working with physiotherapist with progressive resistance exercises and balance training; work with occupational therapist for gait aids, environmental modifications to facilitate return to ADLs despite disability
Visualspatial- can try eye patches, simple cues to the neglected side
Psychological support with counselling/psychologist to further engage motivation and hope in rehabilitation
Cognitive issues- cognitive rehabilitation with neuropsychologist
Educate the carers/family members about how to manage the patient post discharge from rehab!
125
what is aricept?
donezapil
126
what are the 3 general groups of causes for a geriatric fall?
extrinsic factors
intrinsic factors
behavioural factors
127
SE of memantine?
dizziness, drowsiness, headache, confusion, bradycardia
128
how might we prevent pressure ulcers in an elderly, ill patient?
1. Pressure relieving mattress
2. Proper risk assessment of pressure ulcers by nursing team; and regular monitoring
3. Optimise mobility/nutrition and fluids
4. Interventions such as continence training and using trapeze bars to help reposition
5. Nursing care staff can also help reposition the patient
6. good skin care and skin hygeine
129
what are some goals of rehabilitation post amputation?
1. Postop pain + wound management
2. Prevention of complications such as contractures and wound infection + pressure ulcers; thromoboembolism prophylaxis
3. Fitting and casting of prosthesis if relevant
4. Wheelchair independence if relevant
5. Medical management- secondary prevention (e.g. manage HT, hypercholesterolemia, diabetes, nutrition etc)
6. Psychosocial support- early identification and tx of depression and anxiety
7. Management of ADLs/PADLs/CADLS with social worker and OT (OT home review)
8. Support and education to carers/family members- family meeting
130
how might we manage stump swelling?
using a rigid cast shaped to the size of the stump
131
When might you consider neuroma pain in a patient who has undergone a previous limb amputation?
when the patient complains of sharp shooting pain, distal to the stump and it continually increases post surgery or presents for the first time (can often be misdiagnosed as phantom pain).
132
how might you ix neuroma pain and mx in a patient with an amputated limb?
MRI
| surgical resection or injection of an anaesthetic
133
what are some rehabilitation goals for a prosthesist assisting with a patient who has undergone lower limb amputation?
1. Preparation of patient for prosthesis: optimise medical management and pain, control of stump swelling/pain, improve arm and shoulder strength, improve core strength and balance on one leg
2. encourage and facilitate independent transfers
3. Gait training with prosthesis
4. Liaise with outpatient physiotherapist to maximise quality of gait and posture while prosthetic tolerance increases.
5. Liaise with OT for suggested environmental modifications
134
what are some follow up options/advice for a patient who has had an amputation and now is using a lower limb prosthesis?
Review in amputee clinic with rehab physician annually
Prosthetic reviews with prosthesist
Prevent weight gain; optimise other medical conditions eg. diabetes/PVD
refer to podiatrist/ DFU clinic
ensure ongoing management by GP in community
135
what are some aspects that may hinder successful prosthetic rehab?
1. uncontrolled comorbidities and pain
2. poor wound healing
3. Medical complications post op
4. Poor mobility
5. Physical disability (preexisting)
6. severe depression/anxiety
7. Lack of motivation
8. inaccessible home environment and lack of support
136
what are some knee precautions post knee arthroplasty?
patients are advised not to kneel or squat.
137
what are the acute management priorities when an elderly patient is found to have a NOF?
1. pain management
2. stabilise medical comorbidities
3. prevent pressure ulcers and thromboembolism
4. Surgery as soon as practical- reduction, fixation and early mobilisation
138
what type of surgery is indicated for a garden 1 subcapital fracture?
cannulated screw or DHS
139
what is the surgical procedure of choice for displaced subcapital/intracapsular fractures?
hemiarthroplasty
140
when is a dynamic hip screw used?
intertrochanteric fracture or non-displaced intracapsular fracture
141
when is an intramedullary rodding procedure done?
for subtrochanteric fractures
142
what are some complications of hip fractures?
```
AVN
non-union
infection
DVT/PE
dislocation after hemiarthroplasty
prosthetic loosening following elective THR for OA
peri-prosthetic fractures
```
143
what are some practice principles for a PT assisting a patient post stroke with shoulder pain and subluxation?
1. shoulder strapping and interventions to educate staff/carers on how to manage affected limb may prevent pain and subluxation
2. firm support devices may prevent further shoulder subluxation
144
what are the 3 types of intracapsular NOFs?
subcapital, transcervical, basicervical
145
what are the 2 types of extracapsular NOFs?
intertrochanteric, subtrochanteric
