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Phase 4 > Geriatric medicine > Flashcards

Geriatric medicine Flashcards

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1
Q

What can be seen microscopically on osteoporosis?

A

Reduced Tubercle
Thinning of cortical bone
Widening of harverian systems

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2
Q

Which areas are most at risk of developing pressure sores and must be regularly checked?

A 
Sacrum 
Iliac Crest 
Greater trochanter 
Heels 
Malleolus
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3
Q

What scoring systems can be used to assess pressure ulcers?

A

Norton Scale for pressure sores

Waterloo pressure score risk assessment

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4
Q

What is the first line treatment for alzheimer’s disease?

A

Acetylcholinesterase inhibitors

  • donepezil
  • galantamine
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5
Q

What are some of the deterioration seen in the gait of the elderly?

A

Difficulty rising

Unsteady on standing

Unsteady gait

Unsteady on turning

Unsteady sitting down

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6
Q

Define what is meant by disability, frailty and comorbidity

A

Disability indicates established loss of function

Frailty indicates increased vulnerability to loss of function / unable to withstand illness without loss of function

Comorbidity indicates multiple diagnoses

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7
Q

How can frailty be assessed?

A

By measuring the physiological function across a number of domains.

Fried Frailty score
Handgrip strength

Walking speed

Self reported exhaustion

Physically active

Loss of weight within 1 year

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8
Q

Name complications in diagnosis of disease in old age:

A
  • Present late
  • Present with atypical symptoms
  • Low functional status making seeing differences harder
  • Multiple pathologies

Late presentation
- patient often presume symptoms are part of getting old

Atypical presentation

  • pain receptors are blunted
  • M.Is often present differently
  • delirious presentation

Acute illness and changes of function are not as obvious

  • feel a bit off
  • pyrexia response if not the same

Multiple pathology
- the symptoms could be sourced to numerous different causes

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9
Q

What are some risk factors for falls?

A

History of falls

Muscle weakness

Gait or balance abnormalities

Visual disturbance

Cognitive impairment

  • delirium
  • dementia

Poor vision

Vertigo

Drugs

  • Sedatives
  • antipsychotics
  • antidepressants
  • anti - hypertension
  • more than 4 medications is a risk factor

Acute illness

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10
Q

If someone falls what management should be undertaken?

A

Following appropriate assessment and ABCDE:

  • Community Falls prevention programme
  • Environmental assessment by OT
  • Referral to falls clinic
  • ATAGO exercise programme
  • footwear/ footcare
  • specific managements
  • medications
  • postural hypotension
  • osteoporosis
  • visual optimisation
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11
Q

How can physiotherapists help against falls?

A

Strengthening exercises

Balance exercises

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12
Q

What can be measured to assess risk of falls?

A

Sitting to standing time

Rise out of chair

Timed up and go test

Grip strength

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13
Q

What are the super six exercises that done for falls prevention at community rehab centres?

A 
sit to stand 
heel raises 
toe raises 
one leg stands 
heel to toe 
heel to toe walking
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14
Q

How are the outcomes of community falls prevention services measured?

A

Tinetti Assessment

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15
Q

What are the interventions done to fall preventions in older people?

A

Individual or group strength and balance classes

Rationalism of medication

Correction of visual impairment

Home environmental hazard assessment

Calcium and Vitamin D supplementation

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16
Q

What are the types of urinary incontinence that can occur?

A

Functional Incontinence
- unable to make it to the toilet

Passive incontinence
- Decline in cognitive ability

Stress incontinence
- Weak sphincter vs intra abdominal pressures

Over active bladder

  • Psychological
  • Neurological conditions
  • Small bladder

Overflow Incontinence

  • prostate enlargement
  • pelvic mass
  • neurological conditions
  • in the absence of UTI
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17
Q

How is passive incontinence treated?

A

Physiotherapy
Walking aids - OT
Devices - Urisheaths
Urinary pads

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18
Q

How is Stress incontinence treated?

A

Conservative

  • reduced caffeine
  • Reduce BMI

Pelvic floor exercises
- 8 x 10secs contraction x 3 daily

Surgery

  • Colususpsion
  • mid Urethral sling
  • urethral bulking
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19
Q

How is a overactive bladder treated?

A

Bladder training

Anticholinergic/ Anti - musuranics

Beta 3 Agonists

Botox

Sacral Nerve stimulation

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20
Q

What are some causes to faecal incontinence?

A

Anal sphincter dysfunction

  • structural damage
  • surgery
  • birth
  • radiation
  • weak pelvic floor

Faecal overflow - long term constipation

  • opioids
  • neuropathic dysmotility

Loose stools
- infection

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21
Q

What are some ways of managing faecal incontinence?

A

Referral to incontinence nurse

Bowel training

Encouraging gastric colic reflexes

Incontinence control

Codiene/ phosphate enamea
- brake and accelerator approach

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22
Q

What are the grading scores for ulceration:

A

Stage 1: Non - blanching erythema

Stage 2: Shallow ulcer - epidermal layers

Stage 3: Deep ulcer involvement - thickness to dermis

Stage 4: Full thickness to bone

**grades 3-4 require to be reported to a serious incident

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23
Q

What is the definition of elderly abuse?

A

A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an elderly person

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24
Q

What are the five most common types of elderly abuse?

A

Physical

Psychological

Financial

Sexual

Neglect

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25
What are some causes of malnutrition in the elderly?
Social isolation Unable to access food Decline in senses - taste - smell * no activation of hunger Decreased compliance/ relaxation of stomach - early satiety
26
What is a scoring system that can be carried out to assess the nutritional status of someone?
MUST score
27
How does frontotemporal dementia present?
Social disinhibition and family history *Anti- ACh and Mematamine are not recommended
28
What are some investigations into sarcopenia?
Nutritional assessment Cadence speed Grip strength Bioelectrical analysis of muscles
29
List some causes for sarcopenia:
Cancer/ Chronic disease lack of physical activity poorer nutritional intake reduced motor units Hypo-vitamin D
30
What are the risk factors for osteoporosis?
``` Steroids Hyperparathyroidism/ Hypothyroidism Alcohol Low BMI Reduced Testosterone Menopause Renal Failure Erosive bone disease Dietary ```
31
What investigations can be done into Osteoporosis?
DEXA Scan - lumbar of spine - Proximal femur Calcaneal Quantitative Ultrasound Scan
32
What is the management for osteoporosis?
Lifestyle measures - weight lifting - reduce smoking - reduce alcohol Assessment for falls Medications: - Bisphosphonates - hormone replacement - Denosumab - Anti RANKL
33
What are the common visual changes that occur in the elderly?
Visual Acuity changes | Cataracts
34
What DEXA score would give a diagnosis of osteoporosis?
T
35
Out with cognitive decline and memory, what other symptoms are associated with dementia?
Agitation Aggression apathy
36
Out with dementia screening tools such as AMTs and MMSE, what other investigations should be done into dementia?
Look for reversible and organic causes: - TSH - B12 level/ Folate - Calcium level - Alcohol? - thiamine Head MRI - vascular - encephalitis EEG
37
What are the subtypes of dementia?
Alzheimer's disease Vascular dementia - sudden onset Lewy Body Dementia - fluctuating cognitive impairment - progresses to Parkinson's disease * characterised by eosinophilic cells on histology Frontotemporal Dementia - Onset before 65 - exudative dysfunction - personality changes - emotional unconcern - episodic memory etc is persevered until quite late on
38
When should alzheimer's be suspected?
>40 years old + - progressive global cognitive impairment - reduced viso-spatial skill - memory - verbal abilities - executive functioning
39
What are some risk factors for developing Alzheimer's disease?
1st degree relative Down's syndrome Apolipoprotein E/ ApoE Reduced cognitive/ physical activity Depression/ loneliness Smoking
40
What is the pharmacological management of dementia?
Acetylcholinesterase Inhibitors - Donepezil - Galantamine - Rivastigmine Glutamate antagonists - Memantine Vitamine supplementation - Vitamin E
41
What are some side effects of Acetylcholinesterase inhibitors?
Peptic Ulcers Heart Block *bradycardia is contraindicated with actely-cholinsterase inhibitors
42
What is the prognosis of Alzheimer's disease?
7 year survival from diagnosis
43
What are some other causes of depressive symptoms in elderly patients?
Grief Hypothyroidism Dementia Dysthymia (persistent low mood)
44
What is the definition of a fall?
An unexpected event which results in the patient coming to rest on the ground, floor or lower level. A fall doesn’t strictly have to be a collapse to the ground. It may be stumbling backwards into a chair or toilet.
45
What screening tools can be used for delirium?
4AT - alertness - Orientation to time and place - Months backwards - fluctuation AMT
46
List some causes of false positives/ negatives for dementia/ delirium on screening tools:
False Positives: - language barrier - Nerves of patient - Feeling ill False Negatives: - Previous heard answers - poor Testing technique - Education levels (someone well educated may pass certain tests, yet still had a significant reduction in their cognitive ability)
47
What recommended screening tools can be used for dementia/ cognitive decline?
MMSE/ MSE Addenbrooke's Cognitive test MOCA
48
What investigations should be done when a patient presents after falling?
Beside tests: - basic observations - BM glucose - Blood pressure - Urine dip - ECG Bloods: - FBC - U&Es - LFTs - Bone profile Imaging - x-ray of injuries - CT of head if injured - Echo cardiogram
49
What scoring system can be used to assess patients at risk of developing pressure sores?
Waterloo score
50
Compare and contrast delirium vs dementia:
Delirium: - abrupt onset - Fluctuating course - Short duration - days/ weeks - Attention severely affected - Sleep wake cycle distributed - Incoherent speech (as opposed to impoverished)
51
Which Type of dementia is most associated with visual hallucinations?
Lewy Body Dementia
52
What are some physiological changes that occur in aging?
Reduced Respiratory Functioning Reduction in renal function Bone mass loss 25-50% loss of muscle Visual deterioration Brain atrophy Neurosensory disturbance
53
What is the best intervention for frailty in the elderly?
Comprehensive Geriatric assessment
54
What is a comprehensive geriatric assessment?
Multidimensional interdisciplinary diagnostic approach to determine the physical, psychological and functional capacities of a frail elderly person - in order work out an integrated treatment with long term follow up.
55
What are the 6 M's?
Matter most to the patient - DNACPR Mind - delirium - depression - dementia * 4AT, AMT, further testing Mobility - Barthel Score Medications - Polypharmacy Multi Comorbidities Me and Mine - who helps them?
56
What does the 4AT consist of?
Alertness AMT4 - age - DOB - Place - Year Attention - months backwards Acute or fluctuating consciousness
57
Where do the majority of falls take place?
Outside
58
What should the managed be for an elderly person who falls in the community?
Referral to Community falls prevent programme Environmental assessment by and screening by OT Referred to falls clinic
59
What is the management for an elderly person who falls and attends hospital:
A&E referral to community falls prevent programme All patients have a Falls risk assessment done within 24 hours Falls policy for inpatients
60
What are the best recommendations for falls prevention?
Adaptation and modification to home Exercise training - strength - balance - Gait training Withdrawal, minimisation of psychoactive medication Withdrawal, minimisation of other medications Management of postural hypotension Management of foot problems
61
What happens at a falls clinic?
Nurse assessment: - incontinence - AMT - visual acuity - ECG - Medication Physio - Full neuromuscular exam - Tinetti - get up and go test Medical - History - exam - Vertigo testing Clinical psychology MDT - list of problems and investigations needed - referral to Strength and balance classes - Community falls prevention class
62
What are the implications of a fall?
Personal impact to patient Prolonged hospitalisation Increased mortality and morbidity Litigation
63
What equipment can be put in place at the hospital to help prevent falls?
Bed monitors Chair monitors Non slip mats/ one way glides specialist seating
64
Name a falls risk assessment:
Cannard Falls risk assessment | >18+ needs referral
65
What are the causes for delirium and how is it managed?
MIST: Metabolic abnormalities - hyponatremia - hypercalcaemia - Hypoglycemia Infection - UTI - Malaria - Wounds Surgical/ Stroke - post Orthopaedic Toxins/ Drugs - Dopamine agonists - Anticonvulsants + Constipation Treatment: - reorientation - ensure glasses are being worn - clocks/ calendars in sight - Family members - Removal of indwelling devices Medical treatment: - Haloperidol 2nd line: - benzodiazepines
66
What investigations/ Management should be done into delirium?
4 AT TIME check list: T - Triggers (Causes) I - Investigations - FBC - CRP - U&Es - Urine Dipstick - CXR? M - Manage E - Engage with families and friends
67
Define delirium:
Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking, and altered levels of consciousness. with characteristics of: - hyperactivity - hypoactivity - mixed picture - hallucinations
68
What are the differentials for delirium?
Dementia Stroke Metabolic disturbances - hypoglycaemia Status epilepticus Hypoxia
69
What are some risk factors for delirium?
>65 Dementia Recent surgery - hip surgery Acute illness Psychological agitation Polypharmacy Renal impairment
70
What are the giants of geriatrics?
Instability Imbolility Incontinence Intellectual Impairment
71
What is the diagnostic criteria for dementia?
``` Impaired short and long term memory + (at least two) - Poor judgement - dysphasia - Dyspraxia - Agnosia (poor recognition) - Personality change ``` Interference with work and social living
72
What is the diagnostic criteria for delirium?
Acute change in mental status Inability to maintain attention Disorganised thinking Altered level of consciousness
73
What is the detrimental outcomes of delirium?
Increased hospital stay increased mortality Increased cost to NHS Increased risk of dementia
74
What initial things do you want to do when someone comes in with a fall?
ABCDE - the D will probably be the major thing here. - Blood glucose - ECG - BP standing and sitting - CT head?
75
What investigations should be done into urinary incontinence?
Urine dipstick Review of drug history (ACE inhibitors can make stress incontinence worse) Urinary diary Urodynamic studies
76
What is the exercise program for the elderly that is used?
OTAGO
77
What is histologically seen with Lewy Body Dementia?
Eosinophilic Cytoplasmic inclusion bodies
78
What proteins are seen in fronto-temporal dementia?
Tau proteins
79
What non-pharmacological measures can be done for dementia patients?
Aromatherapy Multisensory stimulation Massage Music Animal assisted therapy
80
What are some of the causes of dementia?
Degenerative - AD - Lewy body Vascular Metabolic - liver failure - uraemia Infections - HIV - Neurosyphilus Endocrine - hypothyroidism
81
Which type of dementia should not be treated with acetylcholinesterase inhibitors?
Vascular Frontal temporal dementia
82
What do you do when you suspect elderly mistreatment?
Interview patient alone Seek senior help Alert police or social worker * if they lack capacity then the relevant people must be contacted. This is under the: - Adult Support and Protection Act 2007

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