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Clinical Years / Progress Test > Geriatrics > Flashcards

Geriatrics Flashcards

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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
What is the cumulative deficit model of frailty
Describes frailty as a state 92 baseline variables classed as present or absent Can relate to clinical frailty scale
26
What is the clinical frailty scale
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
27
What signs can be picked up of frailty on physical examinations
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
28
How can factors for falls be assessed
Drugs Ageing related Medical causes Environmental
29
What is BPPV How is it diagnosed and treated
Benign paroxysmal positional vertigo Vertigo that occurs in short spells and with head movements Diagnosed using Dix-hallpike manoeuvre Treated with Epley manoeuvre
30
What investigations should be done in a falls patient
FBC - anaemia and infection markers Blood glucose U&Es - electrolyte abnormalities TFTs B12 and folate Bone profile Vit D ECG
31
What is a frax calculation
Works out the 10 year fracture risk
32
What is the first line treatment for osteoporosis
A bisphosphonate such as alendronic acid 70mg once weekly Alongside calcium and vitamin D
33
What age related changes affect normal blood pressure regulation so can lead to syncope
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
How is a stroke diagnosed
FAST test in the community NIHSS scale to indicate severity CT scan to decide ischaemic or haemorrhagic
35
What treatment is done once a haemorrhagic stroke is excluded
300mg aspirin Thrombolysis with alteplase if within 4.5 hours of symptom onset and no exclusion criteria present
36
What are the main risks of thrombolysis
6% risk of haemorrhage (2-3% life threatening) 7% risk of angioedema
37
What is a lacunar stroke / lacunar syndrome ?
Subcritical stroke due to small vessel disease Diagnosed by 1 of: - unilateral weakness - pure sensory stroke - ataxic hemiparesis
38
What is posterior circulation syndrome?
Stroke in the posterior circulation Diagnosed by 1 of - cerebellar or brain stem syndrome - loss of consciousness - isolated homonymous hemianopia
39
What is a total anterior circulation stroke and partial anterior circulation stroke
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
How does a haemorrhagic stroke tend to present
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
How can you differentiate a stroke in the anterior vs middle cerebral artery
Anterior tends to be lower extremity affected more Middle tends to be upper limb affected more + aphasia more likely
42
What symptoms with posterior cerebral artery stroke
Contra lateral homonymous hemianopia with macular sparing Visual agnosia
43
What is Weber’s syndrome
Midbrain stroke Causes ipsilateral CNIII palsy Contractural upper and lower limb weakness
44
How does a posterior inferior cerebellar artery stroke present
Ipsilateral facial pain and temp loss Contra lateral limb and torso pain and temp loss Ataxia and nystagmus
45
Anterior inferior cerebellar artery stroke
Ipsilateral facial paralysis and deafness + same as posterior inferior cerebellar stroke
46
Retinal/ophthalmic artery stroke
Amaurosis fugax - transient visual loss
47
Basilar artery stroke
Locked in syndrome
48
what are the core clinical features of Parkinson's disease
bradykinesia resting tremor rigidity
49
what is the pathophysiology of PD
Lewy bodies causing loss of dopaminergic neurones in the basal ganglia, particularly the substantia nigra
50
diagnostic criteria for PD
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
what red flags indicate a diagnosis other than idiopathic Parkinson's disease
symmetrical at onset pyramidal tract signs early falls poor levodopa response brisk reflexes and positive babinski
52
what are the main differential diagnoses of PD
vascular Parkinsonism supra nuclear gaze palsy multiple system atrophy dementia with lewy bodies Drug induced Parkinsonism Normal pressure hydrocephalus
53
what are the non-motor features of PD
- mood disorders mainly depression - constipation, urinary retention and erectile dysfunction - cognitive impairment - psychotic featyres - olfactory deficit - pain - sleep disorders
54
where/how in the brain do different PD medications target?
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
what drugs for PD act in the peripheries enhance dopamines effects
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
what drug acts centrally to enhance dopamines effect
MAO-B inhibitors reduce breakdown of dopamine in the CNS e.g. selegiline rasagiline
57
how does levodopa compare to direct dopamine agonists
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
what is dyskinesia? when does it occur
involuntary twisting writhing movements induced by dopamine, worse with prolonged treatment - increased dyskinesia and less levodopa effect
59
What is an essential tremor
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
How does drug induced Parkinsonism present
History of dopamine blocking drugs such an antipsychotics Usually symmetrical rigidity and lack of facial expression
61
How does multiple systems atrophy present
Symmetrical Parkinsonism with early autonomic features such as hypotension and bladder instability
62
How does progressive supranuclear gaze palsy present
Falls, truncated rigidity, vertical gaze palsy and reduced midbrain volume on MRI
63
What is the triad of normal pressure hydrocephalus How is it treated
Dementia, gait disorder and bladder instability Diagnostic lumbar puncture and CSF removal then shunt
64
Examples of dopamine agonists When can they be used
Ropinirole, pramipexole, rotigotine Can be used first line
65
What are the 4 stages of Parkinson’s disease progression
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
What is the Waterlow score
Identifies patients at risk of pressure ulcers
67
When should a FRAX calculation be done
assess fracture risk in - anyone over 50 with a history of falls - all women over 65 - all men over 75
68
treatment for osteoporosis
bisphosphonate (alendronic acid) + calcium + vit D
69
bisphosphonate contraindications
chronic kidney disease or pre-existing dysphagia or dyspepsia
70
drug induced Parkinsonism
Hx of dopamine blocking drugs symmetrical rigidity and lack of facial expression reduce of stop drug - need to liaise with psychiatry
71
areas assessed in NIHSS score
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
first line pharmacological treatment for delirium
0.5mg haloperidol Contraindicated in Lewy body dementia and parkinsonsims
73
absolute thrombolysis contraindications
- 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
relative thrombolysis contraindications
concurrent anticoagulation INR (>1.7) major surgery in previous 2 weeks active diabetic haemorrhagic retinopathy
75
definition of postural hypotension
drop in BP of >20mmHg systolic and/or >10mmHg diastolic within 3 minutes of standing
76
causes of postural hypotension
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
postural hypotension non-pharmacological management
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
pharmacological management of postural hypotension
Fludrocortisone; mineralocorticoid that expands plasma volume Midodrine; vasopressor useful in neurogenic PH Pyridostigmine; has a vasopressor effect whilst standing
79
questions to ask in a nutritional assessment
- 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
how is a MUST score calculated and used
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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