Geriatrics - * / 1 Flashcards
(45 cards)
Delirium definition
acute, reversible syndrome of impaired higher cortical function hallmarked by generalised cognitive disturbance caused by one or more aetiologies
Confusion, disorientation, agitation
20% of patients on med and surg wards
Rx of delirium
Non-drug: treat in low stimulus, well lit room, relative present, clock and window, reduce stress, prevent accidents, improve orientation
Treat precipitant: minimise medication, ABx for HAP
Pharm: haloperidol / lorazepam
SSx of delirium
Acute/subacute onset, fluctuates, disturbed consciousness, reduced awareness of environment, reduced focus, sustain, shift of attention, cognitive deficits, sleep-wake disturbance, slow, muddled thinking with complex content, language impairment, psychosis, psychomotor behavioural disturbance, altered / labile affect
8 signs of delirium
DELIRIUM
Disordered thinking: slow, irrational, rambling, jumbled up, incoherent ideas
Euphoric, fearful, depressed or angry: labile mood, e.g. anxious then torpid
Language impaired: speech is reduced or gabbling, repetitive and disruptive
Illusions/delusions/hallucinations: tactile or visual (auditory suggests psychosis)
Reversal of sleep-awake cycle: may be drowsy by day and hyper-vigilant at night
Inattention: focusing, sustaining or shifting attention is poor, now real dialogue
Unaware/disorientated: doesn’t know if its evening, own name or location
Memory deficits: often marked
Causes of delirium
CHIMPS PHONED
Infection - pneumonia, UTI, malaria, wounds, IV lines, encephalitis, meningitis
Drugs - opiates, anticonvulsants, levodopa, sedatives, recreational, post-GA, withdrawal
Metabolic - AKI, uraemia, liver failure, Na/glucose, reduced Hb, malnutrition, hypothyroid, cushings
Hypoxia - resp / cardiac failure, stroke, MI
Intracranial - raised ICP, SOL, epilepsy
Nutritional - thiamine, nicotinic acid, B12 deficiency
Constipation, hypoxia, infection, metabolism, pain, sleep, prescriptions, hypothermia, organ dysfunction, nutrition, environment, drugs
Ix of delirium
Hx including drug Hx coexisting medical / psych disorders Physical exam Urine dip / drug screen FBC, Ca, U&E, LFT, blood glucose, folate / B12, INR, PT, malaria films, ammonia, septic screen, ABG, EEG, LP, CT/MR, dehydration, electrolyte imbalance
How does disease present in the elderly
Vague - non-specific signs of illness
confusion, self neglect, falling, incontinence, apathy, anorexia, dyspnoea, fatigue
atypical presentation of infectious diseases in the elderly
absence of fever
Sepsis without usual leucocytosis and fever
Falls, reduced appetite or fluid intake, confusion, change in functional status
presentation of “silent” acute abdomen in elderly
Absence of symptoms (silent presentation)
Mild discomfort and constipation
Some tachypnoea and possibly vague respiratory symptoms
Presentation of “silent” malignancy in elderly
Back pain secondary to metastases from slow growing breast masses
Silent masses of the bowel
Presentation of “silent” MI in elderly
Absence of chest pain
Vague symptoms of fatigue, nausea and a decrease in functional status.
Classic presentation: shortness of breath more common complaint than chest pain
Causes of falls in elderly - DAME
Drugs
Age-related - nerves, muscles, gait, posture
Medical co-morbidities
Environmental
Physiology of ageing
Vision: reduced sigh in low illumination, sunken eyes (loss of fat), cornea translucency, arcus senilis, decreased pupil diameter, lens becomes presbyotic, increase in annular layers, buckling and kinking of the rods and a decline in the number of cones
Hearing: dry wax build up, degeneration of hair cells and lining cells, presbycusis (degeneration of cochlea) and changes I articular cartilage
Sensation: increased thresholds, reduced speed of impulses
Central: impaired processing and coordination
Muscle: 1.5% reduction in bulk a year, fibre numbers and diameter, slower to contact and longer to reach peak conditions
Balance: decreased vestibular visual impulses
Posture: kyphosis, walking aids, elbow more flexed, shoulder more extended, increased base of support
Gait: decreased stride length, cadence, range of movement, plantarflexion, vertical head movements
Psychological: confidence
Consequences of falls in elderly
Immobility
Injury - fractures, head injury
fear, reduced confidence, independence, low mood, loneliness
2o - chest infection, pressure sore, dehydration, muscle atrophy, pain, burns, hypothermia, rhabdomyolysis
Fall Hx
Before - pre symptoms, what were they doing, mobility
PMHx
Meds
During - remember, witnessed, LOC, mechanism of fall, hands out, hit head
After - jerking, incontinence, well-orientated, able to mobilise, how long on floor
Syncopy causes
Had they eaten?
Low lighting?
Common investigations post fall
Bloods (anaemia, dehydration, hypo, thyroids, B12, folate, HbA1c, calcium, phosphate) Urine dip Postural BPs Cardiac assessment + ECG (arrythmias) +/- Echo / 24-hour tape CXR Pelvis XR (if indicated) CT head (if indicated) Visual acuity assessment Gait assessment Check feet and footwear Assess home environment Assess cognition
MDT approach to preventing falls
Drug review Treat cause Strength and balance training Walking aids Environmental assessment and modification Vision Reducing stressors
Syncope definition
Sudden, transient LOC due to reduced cerebral perfusion, unresponsive pt with loss of postural control
Causes of syncope
Peripheral factors - hypotension (orthostatic, eating, straining, or coughing) +/- dehydration, hypotensive drugs, or concurrent sepsis
Vasovagal syncope (‘simple faint’) - Vagal stimulation (pain, fright, emotion, etc.) leads to hypotension and syncope
Usually, an autonomic prodrome (pale, clammy, light-headed) is followed by nausea or abdominal pain, then syncope.
Benign, with no implications for driving.
Diagnose with caution in older people with vascular disease where other causes are more common
Carotid sinus hypersensitivity syndrome
Pump problem - MI or ischaemia, arrhythmia (tachy- or bradycardia, e.g. ventricular tachycardia (VT), supraventricular tachycardia (SVT), fast atrial fibrillation (AF), complete heart block, etc.)
Outflow obstruction, e.g. aortic stenosis, PE
Stroke and TIA rarely cause syncope -> focal not global deficit (brainstem ischemia is the rare exception)
Seizure disorder is main differential
Physical, psychological and social causes of immobility in old age
Physical: neuro, sensory deprivation, CVS/resp disease, MSK
Psychological: fear, anxiety, depression
Social: reduced income, nowhere to go, loss of choice, no reason
Prevention of immobility
Maintain physical health / fitness Treat medical problems early Financial planning Hobbies Interests
Rehabilitation post immobility
Restoration of the individual to the optimal levels of ability within the needs and desires of the patient and family
Team work
Controlling underlying disease
Prevent complications
Retrain - physio for mobility, nurses for bladder / bowels
Adaptations
Pressure ulcers
area of localised damage to skin and underlying tissue caused by pressure, shear, friction or a combination of these
Represents a major burden of sickness and reduced quality of life
Require prolonged and frequent contact with healthcare system, suffer pain, discomfort and inconvenience
Presence of pressure ulcers has been associated with 2-4x risk of death of older people in ITU
Pathogeness of pressure ulcers
Soft tissue compression between bone and external surfaces, causing tissue necrosis
