geriatric medicine Flashcards
(34 cards)
What are some important points in a geriatric history you need to cover in addition to a normal history?
- Falls history
- Assessment of cognition (check with collaterals if change)
- Continence assessment
- Social and functional history (where do they live, do they have carers, do they have adaptations in home)
- Further systemic enquiry
- Advanced care planning
what is involved in a cognitive geriatric assessment?
Problem list (current and past)
Medication review
Nutritional status
Mental health
Functional assessment: basic ADL, gait, functional ADLs
Social circumstances
Environment
What do you need to sort out before a patient can be discharged?
TTO (medication to take home)
Transport
Therapy assessment (physio and OT)
Outpatient appointments
Restarting package of care
Transfer back letter for residential residents
What is frailty and some examples of frailty syndromes?
Distinctive health state related to the aging process inwhich multiple body systems gradually lose their inbuilt reserve
Use Rockwood clinical frailty score
Frailty syndromes: falls, immobility, delirium, incontinence, susceptibility to side effects of medications
What are some causes of falls in the elderly?
Non-Syncopal
Impaired vision
Home hazards
Drug side effects affecting balance and BP
Dizziness
Syncopal
- Cardiac syncope: ACS, Aortic stenosis, Dysarrhythmias
- Postural Hypotension
- Neurally mediated: vasovagal
what are some causes of cardiac syncope?
arrthymias
valvular disease eg aortic stenosis
cardiomyopathy
PE
aortic dissection
what is postural hypotension?
In first 3 min of standing:
Systolic BP fall > 20 mmHg or
Diastolic BP fall > 10 mmHg
What are some causes of hypovolaemia?
Hypovolaemia (Dehydration, Haemorrhage, Addison’s)
Autonomic failure (Diabetes)
Prolonged bed rest
Drugs eg antihypertensives, anti-anginals, antidepressants,
Alcohol
what is delirium and some causes of it?
Acute confusion state with sudden onset over 1-2 days and fluctuating course. It has a change in consciousness and hyper or hypoalert.
Causes: infections, substance intoxication, substance withdrawal, electrolyte imbalance, hypoxia, constipation, urinary retention
how is delirium screened?
AMT4
AMT10
CAM (confusion assessment method)
What patients are at increased risk of developing delirium and what are the complications of delirium?
Increased risk: cognitive impairment, sensory impairment, surgical patients, hip fracture patients as risk of infection, dementia
Complications: increased mortality, prolonged hospital admission, increased risk of developing dementia
how do you manage delirium?
Supportive care: treat underlying cause, orientate patient to time and place. stop offending medication, resolve infection
Pharmacological treatment (Lorazepam and Haloperidol): only if patient is a harm to themselves or others.
Prevention for those at risk!!!!
How do you assess for dementia?
Collateral history from relatives
Clear history of declining memory over several months
Exclude delirium and depression
- Exclude reversible causes
- Screening tools e.g AMT, MMSE, MOCA
Brain imaging e.g hippocampul atrophy
- Refer to memory clinic
What examinations should you perform for a patient presenting with urinary incontinence?
Abdo exam
PR exam
External genitalia
Urine dipsick and MSU
Post micturition bladder scan
Review of bladder and bowel diary
What are some of the causes of faecal incontinence in the elderly?
- Faecal impaction with overflow diarrhoea
- Neurogenic dysfunction
- Gaping anal sphincter due to haemorrhoids or chronic constipation
What should raise your suspicion of faecal impaction? (rectum full of soft or hard stool)
Smearing
Small amount of type 1 stool
Lots of type 6/7 stool
Mass palpated on abdominal exam
Urinary retention (must always due PR with this to check for impacted rectum and large prostate)
How is faecal impaction managed?
_Hard stool: G_ive stool softener like macrogol then a few days later give stimulant like glycerol or use enema docusate sodium.
Can also give Ispaghula Husk if cannot increase fibre in diet
Soft Stool: Give stimulant or enema
Difficult cases: manual evacuation (risk of perforation outweighed by benefits of improving patient’s symptoms and wellbeing)
Give laxatives prophylactically if elderly and taking another drug that has constipation as a side effect. Always encourage fluids, fibre and exercise!
What is the ABCD2 score?
A tool used to calculate the short term risk of a stroke after a TIA
Calculate by summing up and if 4 or more indicates a high risk:
Age
Blood pressure
Clinical features
Duration of symptoms
Presence of diabetes
how do you manage someone with a suspected stroke?
Immediate 300mg aspirin then take daily
If high risk of stroke (ABCD2 4 or more) then prioritised to be seen in TIA clinic straight away
Ix: carotid doppler, CT or MRI of brain
What are the screening tools for the rapid assessment of a patient presenting with a suspected stroke?
FAST:
Facial drooping
Arm weakness
Speech slurred
Time to call 999
ROSIER:
Determines difference between stroke and stroke mimic in A and E
How is a ischaemic stroke managed in general terms?
Stop/reverse any anticoagulants
Send for CT
Once confirmed ischaemic give alteplase if <4.5 hours since onset
- Also give 300mg aspirin (orally or rectally) and continue this for 2 weeks after stroke, then long term anticoagulation
Rehabilitation
Modify stroke risk factors
what are some stroke mimics?
Seizures
Space occupying lesions
Hemiplegic migraine
MS
Sepsis
What does the CHADVASC score calculate?
The risk of someone with AF developing a stroke
what are some milestones that help you recognise a patient is towards end of life care
Bed bound
Semicomatose
Only able to sip fluid
Unable to take oral medication
