General Geriatrics

Question 1

Common causes of constipation in the elderly?

Answer 1

Dehydration
Diabetes
Low fibre intake
Immobility
IBS
Hypothyroidism
Hypercalcemia
Neurological- Stroke, Parkinson’s
Colorectal cancer
Rectal prolapse

Question 2

How is constipation diagnosed?

Answer 2

ROME IV Criteria

Question 3

How should hard v soft stool impaction be managed?

Answer 3

hard- stool softeners, osmotic laxatives (e.g. lactulose/movicol), enemas

soft- stimulant laxatives e.g. senna

Question 4

Faecal incontinence in the elderly is always abnormal and usually curable. What is it most commonly caused by?

Answer 4

faecal impaction with overflow diarrhoea. This accounts for 50% of faecal incontinence. The second most common cause is neurogenic dysfunction

Question 5

What increases risk of incontinence?

Answer 5

Older female
Obesity
Previous pregnancy
Prolapse
Smoking - chronic cough = strain
Constipation = strain
Neurological dysfunction
Medications

Question 6

What are the key components of a continence exam?

Answer 6

Review of bladder and bowel diary
Urine dipstick and MSU
A post micturition bladder scan
Abdominal examination and PR exam
External genitalia review particularly looking for atrophic vaginitis in females

Question 7

Non pharmacological interventions for incontinence?

Answer 7

Switch to decaff drinks
Improve bowel habit
Regular toileting
Pelvic floor exercises

Question 8

Common drugs for treating overactive bladder?

Answer 8

Mirabegron
Oxybutinin
Tolterodine

Question 9

The MUST score is used to assess patients at risk of malnutrition. What are its 3 components?

Answer 9

current BMI,
history of unintentional weight loss,
likelihood of future weight loss

Question 10

what does NICE recommend for the management of malnutrition?

Answer 10

dietician support if the patient is at high-risk

a food-first approach with clear instructions rather than simply prescribing oral nutritional supplements

if supplements are used they should be taken between meals rather than instead of meals

Question 11

what are the 4 stages of wound healing?

Answer 11

hemostasis,
inflammation,
proliferation,
remodelling

Question 12

Define ‘feed at risk’

What discussions should be had about this?

Answer 12

When a patient can choose to continue eating and drinking despite known risk of aspiration

Discuss signs of aspiration and what to do in case of aspiration with family
Give choking advice

Question 13

What is the evidence for enteral feeding in dementia?

Answer 13

Only to be used in acute illness

No evidence of increased life span and increased risk of aspiration and infection

Question 14

Define delirium.
How do you assess for it?

Answer 14

Acute and fluctuating changes to consciousness, cognition or perception

4AT score

Question 15

What percentage of elderly patients, admitted to hospital, are affected by acute confusional state (delirium)?

Answer 15

up to 30%

Question 16

What are the risk factors for developing delirium (or acute confusional state) ?

Answer 16

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

Question 17

How can delirium be categorised?

Answer 17

hyperactive (agitated and confused), hypoactive
(withdrawn and drowsy) or mixed.

Question 18

What are the main causes of delirium?

Answer 18

PINCH ME

Pain
Infection: esp UTIs
Nutrition: hypo/hyperglycaemia, consider metabolic issues e..g hypercalcaemia
Constipation : consider constipating medications e.g. codeine and ondansetron
Hydration: dehydration, alcohol withdrawal
Medication
Environment: change of environment

Question 19

What factors favour delirium over dementia as a diagnosis?

Answer 19

impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. hallucinations and delusions)
agitation, fear

Question 20

Examinations in acute confusion?

Answer 20

Check for signs of hypoxia
Fluid balance
Mini mental state examination

Question 21

How do you carry out a fluid balance assessment?

Answer 21

Fluid intake and urine output
Cap refill
Pulses and JVP
BP
Skin turgor
Check mucous membranes

Question 22

Investigations in acute confusion ?

Answer 22

Confusion screen bloods
Urine dip (infection)
ECG
CT head

Question 23

What is involved in a ‘confusion screen’ bloods and why?

Answer 23

Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism

Question 24

How is delirium managed?

Answer 24

Tx underlying cause, modify environment, try haloperidol 0.5 mg
(unless pt has Parkinsonism in which case lorazepam 0.5mg )

Question 25

What non pharmacological interventions can help with delirium?

Answer 25

Reassurance Consistency Orientation – clock, pictures, talking, stimulate, family Avoid transfer between wards / less moves Minimise sensory deprivation/overload – ear wax, hearing aids Safe wandering Sleep hygiene – scheduled med rounds, overnight interventions

Question 26

What are the complications associated with delirium?

Answer 26

increased mortality, prolonged hospital admission, higher complication rates, institutionalisation and increased risk of developing dementia

Question 27

What is the GPCOG test?

Answer 27

a test designed as a GP screening tool for dementia

Question 28

Give some risk factors for multi-morbidity

Answer 28

increasing age Female sex Low socioeconomic status Tobacco and alcohol usage Lack of physical activity Poor nutrition and obesity

Question 29

What is the most common comorbid condition?

Answer 29

Hypertension

Question 30

Define fraility. How should it be assessed?

Answer 30

Frailty is defined as a state of impaired homeostasis leading to increased vulnerability to minor stressor events. through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire

Question 31

What topics are covered in the PRISMA-7 questionnaire?

Answer 31

age, sex, health problems, help at home, mobility, social support

Question 32

Give some physical manifestations of frailty

Answer 32

Sarcopenia- loss of skeletal muscle, fat mass may be preserved Unintentional weight loss- disease, ill fitting dentures, inability to make or eat meals Fatigue

Question 33

What is the clinical frailty scale? How is it helpful?

Answer 33

Set of 9 phenotypes ranging from very fit to terminally ill which can be used to summarise the older patient’s overall level of fitness or frailty and predict outcomes of survival/prognosticate

Question 34

What is a CGA?

Answer 34

comprehensive geriatric assessment —> Multidimensional, interdisciplinary diagnostic processes to determine the medical, psychological and functional capabilities of frail older people to develop a coordinated & integrated plan for treatment and long-term follow up

Question 35

What are the domains of a CGA? (7)

Answer 35

Problem list – current and past Medication review Nutritional status Mental health – cognition, mood and anxiety, fears Functional capacity - basic activities of daily living , gait and balance, exercise status Social circumstances Environment - home environment, facilities and safety within the home, accessibility to local resources

Question 36

What are some tools that can be used to see how well a patient is coping with their ADLs?

Answer 36

* Barthel Index * Nottingham Extended activities of daily living

Question 37

What are the “geriatric giants”?

Answer 37

Immobility Instability/falls Incontinence Impaired memory (dementia, delirium) Iatrogenesis

Question 38

What is the Waterlow score?

Answer 38

Used to identify patients at risk of pressure sores

Question 39

what factors increase the risk of pressure ulcers?

Answer 39

malnourishment, incontinence, lack of mobility, pain

Question 40

Outline grades 1-4 of pressure sores

Answer 40

Question 41

Outline the management of pressure ulcers

Answer 41

hydrocolloid dressings and hydrogel to provide a moist wound environment to encourage healing wound swabs taken routinely consider referral to the tissue viability nurse surgical debridement for selected wounds

Question 42

Which tool is used to assess the risk of stroke in the short term post TIA?

Answer 42

The ABCD2 score The ABCD2 score is calculated by summing up the points for five different factors including age, blood pressure, clinical features, duration of symptoms and the presence of diabetes. ABCD2>=4 indicates a higher risk.

Question 43

Give some indications that a patient is reaching the end of life

Answer 43

Bed bound. Semi-comatose. Only able to take sips of fluid. Unable to take medicine orally

Question 44

4 medications used in palliative care?

Answer 44

opioid e.g. morphine anti-emetic anti-secretory - glycopyrronium sedation - benzodiazepine

Question 45

Outline the concept of polypharmacy and how to approach prescribing in the elderly

Answer 45

Polypharmacy is the concurrent use of multiple medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. It is associated with increased hospitalizations and higher costs of care. Reduce dose- often start at 50% of the adult dose Review regularly (can use STOPP START) Give clear instructions

Question 46

What can Trimethoprim do to the kidneys in the elderly population?

Answer 46

False AKI **Transient rise in creatinine levels** by reducing the creatinine excretion of the kidneys. This does NOT reflect the actual GFR and therefore this phenomenon is not reflective of an Acute kidney injury but rather the calculated eGFR

Question 47

A patient is struggling after constantly worrying about their spouse with dementia. What is this often called? How should it be managed?

Answer 47

Carer strain Refer to social services

Question 48

What are the symptoms of carer strain?

Answer 48

Frustration, Self neglect, Isolation from other relationships

Question 49

What percent of carers in England have suffered from carer strain?

Answer 49

75%

Question 50

Give an example of a sequence task that an occupational therapist may assess

Answer 50

Washing and dressing oneself

Question 51

What does the term safeguarding describe?

Answer 51

Measures to protect the health, well-being and human rights of individuals which allow people to live free from abuse, harm and neglect