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Clinical Years / Progress Test > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

How can pressure ulcers be prevented?

A

Support surface
Skin inspection
Movement
Manage incontinence
Nutrition

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2
Q

What is a pressure ulcer

A

An area of localised damage to the skin and underlying tissue caused by pressure

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3
Q

What factors are implicated in the formation of a pressure ulcer

A

Pressure
Shear
Friction
Moisture e.g. from incontinence

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4
Q

How does a pressure ulcer form

A

Decreased capillary flow due to pressure
Ischaemia, occlusion of lymphatic and capillary thrombosis
Pushes fluid out of capillaries
Oedema occurs and leads to cell and tissue death

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5
Q

How are pressure ulcers classified ?

A

Grade 1 - non-blanching erythema, warmth, hardness
Grade 2 - partial thickness skin loss. Looks like an abrasion or blister
Grade 3 - full thickness skin loss involving subcutaneous tissue
Grade 4 - extensive destruction, necrosis or damage to muscle, bone or supportive structures

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6
Q

Risk factors for pressure ulcers

A

Acute illness
Age
Level of consciousness
Cognition
Immobility
Sensory impairment
Chronic or terminal disease
Vascular disease
Malnutrition or dehydration
Incontinence
History of pressure damage

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7
Q

When should antibiotics be used in pressure ulcers

A

All pressure ulcers are colonised with bacteria
Antibiotics should only be used when clinical signs of infection are present and cu litres should be taken to confirm sensitivities

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8
Q

What changes to the bladder and it’s function occur with ageing

A

Bladder contraction frequency increases - increased urge to urinate
Bladder capacity reduces and residual volume increases
Increased urgency and fullness
Increased nocturia

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9
Q

What gender specific changes occur to bladder function

A

Females: reduced tone in sphincters
Urogenital atrophy Due to oestrogen decline

Males: increased frequency but reduced flow
Prostatic hypertrophy, increased urethral resistance and urethral obstruction to varying degrees

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10
Q

What factors can contribute to urinary incontinence

A

Usually multi factorial
- comorbidities
- polypharmacy
- physical and cognitive decline
- lower urinary tract dysfunction

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11
Q

What consequences of urinary incontinence can occur

A

Depress
Falls and fractures
UTIs
Social isolation
Deconditioning

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12
Q

What medication is first line for overactive bladder or mixed urinary incontinence

A

Oxybutynin
Only after bladder training course tried

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13
Q

What is assessed in a continuing care assessment

A

A continuing care assessment decides where/if a person should receive care after hospital
Assesses behaviour, continence, mobility, skin integrity

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14
Q

What are the types of urinary incontinence?

A

Overflow incontinence - involuntary leakage with constant dribbling or dribbling for some times after passing urine
Urge incontinence - involuntary leakage with or just after urgency
Overactive bladder syndrome - urgency with or without urge incontinence usually with frequency and nocturia
Mixed - leakage associated with urgency and also with exertion, effort or coughing
Stress - leakage on exertion, effort or coughing/sneezing

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15
Q

What is a CGA? What does it cover

A

A thorough MDT assessment and formation of a management / follow up plan
Covers:
1. Medical diagnosis and past diagnoses
2. Review of medications and concordance
3. Social circumstances
4. Mood and cognitive function
5. Functional ability
6. Environment
7. Economic circumstances

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16
Q

What is delirium

A

Clinical syndrome of disturbed consciousness, cognitive function or perception with an acute and fluctuating course

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17
Q

Causes of delirium

A

Pain
Infection
Nutrition
Constipation and urinary retention
Hydration

Medication (+ alcohol and withdrawal)
Environment

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18
Q

What tests can be used to assess for delirium

A

Confusion Assessment Method

4AT (short version of abbreviated mental test score AMTS)

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19
Q

How does CAM diagnose delirium

A

Needs both A & B
A: acute onset and fluctuating course
B: inattention

And either C or D
C: Disorganised thinking
D: altered level of consciousness

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20
Q

How does 4AT diagnose delirium

A

4 points or above diagnoses probable delirium

Clearly abnormal alertness 4 points

Age, DOB, current location, current year: 1 mistake 1 point, 2 or more 2 points

List months of year backwards: <7 correct 1 point, cannot assess 2 points

Acute change or fluctuating course 4 points

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21
Q

What is anticholinergic burden?

A

Cumulative effects of medications with anticholinergic effects
Dry mucous membranes, drowsiness, constipation, urinary retention
Increases cognitive impairment, falls risk and overall mortality

Grades medications 0 points to 3 points based on their burden
Score of 3 or more associated with adverse effects

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22
Q

What are the three main types of laxatives? And examples of each

A

Bulk forming - ispaghula husk, methyl cellulose
Osmotic laxatives - lactulose, macrogol
Stimulant laxatives - senna

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23
Q

What is frailty

A

Being vulnerable to poor resolution of homeostasis after a stressor event leading to cumulative decline

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24
Q

What is the phenotype model of frailty

A

Describes frailty as a syndrome with 5 variables
1. Unintentional weight loss
2. Self reported exhaustion
3. Low energy expenditure
4. Slow gait speed
5. Weak grip strength

3 or more frail
1-2 pre frail
0 not frail

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25
Q

What is the cumulative deficit model of frailty

A

Describes frailty as a state
92 baseline variables classed as present or absent
Can relate to clinical frailty scale

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26
Q

What is the clinical frailty scale

A

Scores frailty from 1-9
1 very fit
2 fit
3 managing well
4 living with very mild frailty
5 living with mild frailty
6 living with moderate frailty
7 living with severe frailty
8 living with very severe frailty
9 terminally ill

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27
Q

What signs can be picked up of frailty on physical examinations

A

Vital signs - lying standing blood pressure
Head and neck - cognitive assessment and visual examination
Cardio/respiratory/abdo - fluid overload, valve stenoses, vascular disease, bowels, bladder
Musculoskeletal - joints, muscle bulk, transferring
Skin
Neurological

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28
Q

How can factors for falls be assessed

A

Drugs
Ageing related
Medical causes
Environmental

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29
Q

What is BPPV
How is it diagnosed and treated

A

Benign paroxysmal positional vertigo
Vertigo that occurs in short spells and with head movements
Diagnosed using Dix-hallpike manoeuvre
Treated with Epley manoeuvre

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30
Q

What investigations should be done in a falls patient

A

FBC - anaemia and infection markers
Blood glucose
U&Es - electrolyte abnormalities
TFTs
B12 and folate
Bone profile
Vit D
ECG

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31
Q

What is a frax calculation

A

Works out the 10 year fracture risk

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32
Q

What is the first line treatment for osteoporosis

A

A bisphosphonate such as alendronic acid 70mg once weekly
Alongside calcium and vitamin D

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33
Q

What age related changes affect normal blood pressure regulation so can lead to syncope

A

Reduced baroreceptor sensitivity
RAAS system works less effectively
LV diastolic dysfunction - harder to increase stroke volume
Conduction system disease

Drugs can exacerbate this such as beta blockers, ACEi and diuretics

34
Q

How is a stroke diagnosed

A

FAST test in the community
NIHSS scale to indicate severity
CT scan to decide ischaemic or haemorrhagic

35
Q

What treatment is done once a haemorrhagic stroke is excluded

A

300mg aspirin
Thrombolysis with alteplase if within 4.5 hours of symptom onset and no exclusion criteria present

36
Q

What are the main risks of thrombolysis

A

6% risk of haemorrhage (2-3% life threatening)
7% risk of angioedema

37
Q

What is a lacunar stroke / lacunar syndrome ?

A

Subcritical stroke due to small vessel disease
Diagnosed by 1 of:
- unilateral weakness
- pure sensory stroke
- ataxic hemiparesis

38
Q

What is posterior circulation syndrome?

A

Stroke in the posterior circulation
Diagnosed by 1 of
- cerebellar or brain stem syndrome
- loss of consciousness
- isolated homonymous hemianopia

39
Q

What is a total anterior circulation stroke and partial anterior circulation stroke

A

Cortical strokes that occur in the MCA or ACA
Total or partial determined by 3 or 2 of the following symptoms
- unilateral weakness
- homonymous hemianopia
- higher cerebral dysfunction

40
Q

How does a haemorrhagic stroke tend to present

A

Symptoms tend to progress rapidly (as oppose to very very sudden in ischaemic)
Can be younger patients
Headahce
Most commonly hypertensive either known or unknown

41
Q

How can you differentiate a stroke in the anterior vs middle cerebral artery

A

Anterior tends to be lower extremity affected more
Middle tends to be upper limb affected more + aphasia more likely

42
Q

What symptoms with posterior cerebral artery stroke

A

Contra lateral homonymous hemianopia with macular sparing
Visual agnosia

43
Q

What is Weber’s syndrome

A

Midbrain stroke
Causes ipsilateral CNIII palsy
Contractural upper and lower limb weakness

44
Q

How does a posterior inferior cerebellar artery stroke present

A

Ipsilateral facial pain and temp loss
Contra lateral limb and torso pain and temp loss
Ataxia and nystagmus

45
Q

Anterior inferior cerebellar artery stroke

A

Ipsilateral facial paralysis and deafness
+ same as posterior inferior cerebellar stroke

46
Q

Retinal/ophthalmic artery stroke

A

Amaurosis fugax - transient visual loss

47
Q

Basilar artery stroke

A

Locked in syndrome

48
Q

what are the core clinical features of Parkinson’s disease

A

bradykinesia
resting tremor
rigidity

49
Q

what is the pathophysiology of PD

A

Lewy bodies causing loss of dopaminergic neurones in the basal ganglia, particularly the substantia nigra

50
Q

diagnostic criteria for PD

A
  1. Bradykinesia + tremor or rigidity
  2. absence of red flags indicating another cause
  3. at least one of:
    - response to dopaminergic therapy
    - levodopa induced dyskinesia
    - olfactory loss
51
Q

what red flags indicate a diagnosis other than idiopathic Parkinson’s disease

A

symmetrical at onset
pyramidal tract signs
early falls
poor levodopa response
brisk reflexes and positive babinski

52
Q

what are the main differential diagnoses of PD

A

vascular Parkinsonism
supra nuclear gaze palsy
multiple system atrophy
dementia with lewy bodies
Drug induced Parkinsonism
Normal pressure hydrocephalus

53
Q

what are the non-motor features of PD

A
  • mood disorders mainly depression
  • constipation, urinary retention and erectile dysfunction
  • cognitive impairment
  • psychotic featyres
  • olfactory deficit
  • pain
  • sleep disorders
54
Q

where/how in the brain do different PD medications target?

A

dopaminergic therapies - replace loss of dopamine so more action at D1 and D2 receptors

NMDA receptor antagonists e.g. amantidine block excessive glutamate (inhibitory) action

deep brain stimulation its at the GPm and STN nuclei of the basal ganglia

55
Q

what drugs for PD act in the peripheries enhance dopamines effects

A

decarboxylase inhibitors given with levodopa e.g co-careldopa reduce peripheral conversion to dopamine which can’t cross BBB

COMT inhibitors also increase delivery of L-DOPA e.g. entacapone

56
Q

what drug acts centrally to enhance dopamines effect

A

MAO-B inhibitors reduce breakdown of dopamine in the CNS
e.g. selegiline
rasagiline

57
Q

how does levodopa compare to direct dopamine agonists

A

levodopa (gold standard start first)
- better short term motor improvement
- reduced gait freezing
- more dyskinesia

dopamine agonists
- less efficacy but also less dyskinesia
- more impulse control disorders

58
Q

what is dyskinesia? when does it occur

A

involuntary twisting writhing movements induced by dopamine, worse with prolonged treatment - increased dyskinesia and less levodopa effect

59
Q

What is an essential tremor

A

A condition that’s usually familial
Produces a tremor worse on movement and that may be present in the legs and jaw
Beta blockers effective at reducing the tremor

60
Q

How does drug induced Parkinsonism present

A

History of dopamine blocking drugs such an antipsychotics
Usually symmetrical rigidity and lack of facial expression

61
Q

How does multiple systems atrophy present

A

Symmetrical Parkinsonism with early autonomic features such as hypotension and bladder instability

62
Q

How does progressive supranuclear gaze palsy present

A

Falls, truncated rigidity, vertical gaze palsy and reduced midbrain volume on MRI

63
Q

What is the triad of normal pressure hydrocephalus
How is it treated

A

Dementia, gait disorder and bladder instability

Diagnostic lumbar puncture and CSF removal then shunt

64
Q

Examples of dopamine agonists
When can they be used

A

Ropinirole, pramipexole, rotigotine
Can be used first line

65
Q

What are the 4 stages of Parkinson’s disease progression

A
  1. Pre diagnosis : nigrostriatal degeneration is occurring. Minimal motor symptoms, may have some subtle non motor symptoms
  2. Diagnosis and maintenance : drug treatment commenced with good response and no complications
  3. Complex : motor complications, neuropsychiatric issues
  4. Palliative : door drug response with multiple drugs, Parkinson’s dementia, swallowing and speech impairments. Discussions about end of life care needed
66
Q

What is the Waterlow score

A

Identifies patients at risk of pressure ulcers

67
Q

When should a FRAX calculation be done

A

assess fracture risk in
- anyone over 50 with a history of falls
- all women over 65
- all men over 75

68
Q

treatment for osteoporosis

A

bisphosphonate (alendronic acid) + calcium + vit D

69
Q

bisphosphonate contraindications

A

chronic kidney disease or pre-existing dysphagia or dyspepsia

70
Q

drug induced Parkinsonism

A

Hx of dopamine blocking drugs

symmetrical rigidity and lack of facial expression

reduce of stop drug - need to liaise with psychiatry

71
Q

areas assessed in NIHSS score

A

Consciousness
Pt knows month and age
Eye opening
Best gaze
Visual Fields
Facial Paresis
Right arm
Left arm
Right leg
Left leg
Limb ataxia
Sensation
Language
Dysarthria
Extinction + inattention

72
Q

first line pharmacological treatment for delirium

A

0.5mg haloperidol

Contraindicated in Lewy body dementia and parkinsonsims

73
Q

absolute thrombolysis contraindications

A
  • previous intracranial haemorrhage
  • seizure at onset of stroke
  • intracranial neoplasm
  • suspected SAH
  • stroke of traumatic brain injury in previous 3 months
  • LP is last 7 days
  • GI haemorrhage in last 3 weeks
  • active bleeding
  • pregnancy
  • oesophageal varices
  • uncontrolled HTN >200/120mmHg
74
Q

relative thrombolysis contraindications

A

concurrent anticoagulation INR (>1.7)

major surgery in previous 2 weeks

active diabetic haemorrhagic retinopathy

75
Q

definition of postural hypotension

A

drop in BP of >20mmHg systolic and/or >10mmHg diastolic within 3 minutes of standing

76
Q

causes of postural hypotension

A

Neurogenic
- T2DM (autonomic failure)
- Parkinson’s
- rapidly progressing; amyloid, SCLC

Non-neurogenic; hypovolaemia, cardiac failure or venous pooling
- cardiac impairment; MI, aortic stenosis, HF
- medications; antihypertensives, diuretics, beta-blockers, anti-adrenergic
- reduced intravascular volume; dehydration, adrenal insufficiency
- states that induce vasodilation e.g. fevers

77
Q

postural hypotension non-pharmacological management

A

compression stockings

raise head of bed

increase water and salt intake

patient education and avoiding high risk situations

should always try before pharmacological methods

78
Q

pharmacological management of postural hypotension

A

Fludrocortisone; mineralocorticoid that expands plasma volume

Midodrine; vasopressor useful in neurogenic PH

Pyridostigmine; has a vasopressor effect whilst standing

79
Q

questions to ask in a nutritional assessment

A
  • can the pt feed themselves; any assistance? cutlery?
  • preparing own meals? cooking/microwave? if not who assists?
  • doing shopping? who assists?
  • any change in appetite or weight loss?
  • any problems with dentition or chewing/swallowing?
  • what is their normal intake like? no. of meals, portions etc
80
Q

how is a MUST score calculated and used

A
  1. calculate BMI
  2. any recent weight loss and quantify as a % of body mass; weight loss score
  3. if pt acutely unwell and has their been little intake for >5days; acute disease effect score
  4. add up all scores from 1-3 to give MUST score

0 - routine care
1- monitor intake and aim to improve
2+ - refer to dietician and aim to improve intake

Clinical Years / Progress Test (24 decks)

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