Geriatrics Flashcards
(169 cards)
1
Q
What is frailty?
A
Decline in functional/ physiological reserve –> reduced ability to recover
2
Q
What are the members of an elderly care MDT (10)?
A
- Geriatrician
- Nurse
- Pharmacist
- Dietician
- OT
- Physio
- SALT
- Psychiatrist
- Social workers
- Community nurse
3
Q
What is polypharmacy?
A
5 or more drugs prescribed
4
Q
What is appropriate polypharmacy?
A
Medications that are needed
e.g. for MI prevention
5
Q
What are 2 common causes of inappropriate polypharmacy?
A
- Sequential prescribing/ prescribing cascades
- Pain management
6
Q
What are some consequences of having multiple anticholinergic drugs (2)?
A
- High falls risk
- Altered mental state
7
Q
What are some side effects of anticholingerics (8)?
A
Anticholinergic syndrome:
* Can’t see
* Can’t pee
* Can’t spit
* Can’t shit
* Flushing
* Agitation
* Reduced GCS
* AMS
8
Q
What are some examples of anticholinergics (5)?
A
- TCAs
- Antihistamines
- Antipsychotics
- Paroxetine (most of all SSRIs)
- Oxybutynin (for bladder control)
9
Q
What drugs does warfarin commonly interact with to increase bleeding risk/ INR (2)?
A
- NSAIDs
- Macrolides (clarythromycin/ erythromycin)
10
Q
What does clopidogrel interact with to reduce the efficacy of clopidogrel?
A
Omeprazole - increased clothing risk
other PPIs don’t cause interactions
11
Q
What risk is associated with NSAID and SSRI co-prescription?
A
Higher risk of GI bleed - prescribe a PPI
12
Q
What is ACE-i and spironolactone co-prescription associated with (2)?
A
- High AKI risk
- Hyperkalaemia
13
Q
What can methotrexate and trimethoprim co-prescription cause?
A
Severe bone marrow suppression (myelosuppression)
14
Q
What can statins interact with to increase their levels (2)?
A
- Macrolide
- Grapefruit juice
15
Q
How can iron interact with tetracycline?
A
Reduces levels of tetracyclines
16
Q
What is pharmacokinetics vs dynamics?
A
- Kinetics = body on drug
- Dynamics = drug on body
17
Q
What are the principles of mental capacity act (2005) (5)?
A
- Best interest of patient
- Assume capacity until proved otherwise
- An unwise decision should be accepted (if they have capacity)
- Least restrictive option
- Support to make own decision (give all info)
18
Q
What is an independant mental capacity advocate?
A
Appointed advocate to represent the patient and what is best for them, however cannot make decisions on patients behalf
19
Q
What is a lasting power of attorney?
A
Person appointed by patient to make decisions for them if they were to lack capacity
20
Q
What are the two types of LPA?
A
- Financial
- Medical
or both
21
Q
What is an advanced directive?
A
Written statement by patient detailing what treatment they would/ wouldn’t want to receive, should they lack capacity. This is situation dependant and they cannot demand treatment (only refuse)
22
Q
What is a court appointed deputy (CAD)?
A
Person appointed by a court who CAN make decisions for patient
usually used when depute over patient best interest
23
Q
What is DOLs?
A
Deprivation of liberties - patient lacks capacity so is unfree to leave hospital/ care home if they posy risk to themselves or others
24
Q
What is delirium (acute confusional state)?
A
Acute change in conciseness/ cognition due to underlying pathology
25
What are the causes of delirium (7)?
* **P**ain
* **I**nfection
* **N**utrition
* **C**onstipation
* **H**ydration
* **M**edication
* **E**nvironment + electrolytes
26
What increases the risk of developing delirium (3)?
* Older age
* History of delirium
* Dementia
27
What are the signs/ symptoms of delirium (7)?
* Memory disturbances (short worse than long)
* Agitated
* Disorientated
* Mood changes
* VISUAL hallucinations
* Disturbed sleep cycle
* Poor attention
28
How long should symptoms of delirium have gone on for?
Less than 6 months
*after this point alternative diagnoses become more likely*
29
What is a key feature of delirium?
Fluctuations in severity of Sx
30
What medications can trigger/ exacerbate delirium (4)?
* TCAs
* Opiates
* Parkinsons meds
* Benzos
31
What are the two types of delirium?
* **Hyperactive** - agitation, delusions/ hallucinations
* **Hypoactive** - reduced GCS
32
How is delirium investigated?
* Confusion bloods
* Investigate source of infection (CXR, CT head, urine dip)
* Screening test
33
What confusion bloods should be done on those with delirium (7)?
* FBC
* U&E
* Calcium
* B12/folate
* TSH
* Glucose
* ESR/CRP
34
What screening tests can be used for delirium (2)?
* 4As = **a**lertness, **A**MT4 (age, DOB, name, place), **a**ttention (months backward), **a**cute course
* Short CAM (confusion assessment method)
35
How is delirium treated?
* Orientate = decrease noise, clocks on wall, same staff, family
* 1st = **haloperidol** (for severe agitation)
36
What is important to note in treatment of agitation in those with parkinsons?
Usual first line treatment with haloperidol can worsen Sx of parkinsons
* 1st = atypical antipsychotics e.g. clozapine
* 2nd = benzos
37
What is dementia?
Progressive decline in cognitive function
38
What are the important features of patients with dementia to differentiate it from delirium (3)?
* Patient is alert
* Cognitive decline over more than **6 months**
* Irreversible
39
What are the 4 common causes of cortical dementia?
* Alzheimers = MC (60%)
* Vascular
* Frontotemporal
* Lewy body
40
What is the pathophysiology of Alzheimers?
**Beta amyloid plaques** and **tau neurofibrillary tangles** accumulation in cortex causes axon damage and reduced Ach
41
What are some risk factors for Alzheimers (5)?
* Family history/ genetics
* Older age
* Caucasian
* Female
* Downs (inevitable)
42
What genes are associated with Alzheimers (3)?
* APO-E4
* PSEN 1+2
* APP gene (autosomal dominant inheritance)
43
What are the signs/ symptoms of Alzheimers (4)?
* **A**phasia
* **A**gnosia
* **A**phagia
* **A**mnesia
44
What is the pathophysiology of vascular dementia?
Recurrent ischemic events in the brain damage it --> Sx of dementia
45
What are some risk factors for vascular dementia (8)?
* History of stroke/ TIA
* AF
* Hypertension
* Hyperlipidaemia
* DM
* Smoking
* Obesity
* CHD
46
What is the typical presentation of vascular dementia?
Stepwise or sudden deterioration of cognitive function
47
What are some signs/ symptoms of vascular dementia (5)?
* Poor memory
* Speech disturbance
* Difficulty concentrating
* Focal neurological abnormalities
* Emotional disturbance
48
What is the pathophysiology of Lewy body dementia?
Ubiquitin + **alpha synuclein** (Lewy bodies) build up in the basal ganglia and cortex
49
What is the difference between levy body dementia and parkinsons dementia?
* Lewy body = dementia first then Parkinsonism
* Parkinsons = Parkinsonism then dementia
50
What are some risk factors for levy body dementia (3)?
* Parkinsons
* fHx
* Older
51
What are some signs/ symptoms of lewy body dementia (3)?
* **VISUAL hallucinations**
* REM sleep disorder
* **Fluctuating** levels of consciousness
52
What is the pathophysiology of frontotemporal dementia?
Pick bodies (tau-neurofibrillary tangles + ubiquitin) in frontal/ temporal lobes
53
What genes are associated with frontotemporal dementia (3)?
* TDP-43
* C9ORF72
* MAPT gene
54
When does frontotemporal dementia usually present?
Younger age groups <65
55
What are the signs/ symptoms of frontotemporal dementia (5)?
* Personality change
* Disinhibition
* Relatively preserved memory
* Insidious onset
* Hyperphagia
56
What symptom might indicate involvement of temporal lobe in FTD?
Trouble with grammar/ speech
57
How is dementia investigated (3)?
* Confusion bloods (+ syphilis/ HIV)
* Addenbrookes cognitive examination/ MMSE
* MRI
58
What MMSE score is suggestive of cognitive impairment?
<25
59
What are the signs of Alzheimers on MRI (3)?
* Cortical atrophy
* Enlarged ventricles
* Sulcal widening
60
What are the signs of FTD on MRI?
Frontotemproal deposits
61
What features are suggestive of vascular dementia on MRI?
White cortical deposits
62
What feature is suggestive of Lewy body on MRI?
Cortical/ BG deposits
63
What is a SPECT scan (single positron emission CT) good at differentiating (2)?
* FTD
* Altzheimers
64
What is a DaT (dopamine transporter) scan good at diagnosing?
Lewy body dementia
65
How is Alzheimers managed (2)?
1. Ach-ase inhibitors (**donepezil**, galantamine, rivastigmine)
2. Memantine (NMDA antagonist)
66
What medication should NOT be given to those with Alzheimers?
Antipsychotics
67
What is a contraindication for donepezil?
Bradycardia
68
What is a side effect of donepezil?
Insomnia
69
How is FTD treated?
No approved treatments
*SSRIs, antipsychotics can be given, Ach-ase inhibitors NOT given*
70
How is vascular dementia treated?
No approved treatments
71
How is lewy body dementia treated?
Same as Alzheimers - Ach-ase inhibitors, memantine, NO antipsychotics
72
What are some other causes of dementia (8)?
* **CJD** - rapid dementia within 1 year
* **HIV associated neurological disorder**
* **Normal pressure hydrocephalus** (wet, wacky, wobbly)
* **Alcohol** (Korsakoff)
* **Wilsons** (auto recessive, high copper, keiser fleisher rings)
* **Neurosyphilis**
* **Parkinsons**
* **Huntingtons**
73
What is pseudodementia?
Dementia caused by depression (global memory loss, MMSE often normal)
74
What would be suggestive of delirium rather than dementia (5)?
* Shorter onset
* Impaired consciousness
* Fluctuating Sx
* Visual hallucinations
* Agitation
75
What are some risk factors for falls (7)?
* Weakness
* Vision problems
* Balance/ gait disturbance (e.g. parkinsons, RA)
* Polypharmacy
* Incontinence
* Postural hypotension
* Cognitive impairment
76
How should a patient who has fallen be assessed (4)?
* Circumstances before, during and after fall
* Barthel index (assess **ADLs**)
* Rockwood clinical **frailty** score
* **Fall** risk - FRAT score
77
How should a fall be investigated (4)?
* Bloods
* L/S BP
* ECG
* CXR + CT head
78
What bloods are important in those who have fallen (7)?
* FBC
* U&E
* eGFR
* CK
* Bone profile
* B12/folate
* Vitamin D
79
How is a fall treated (4)?
* Medication review
* Physio + OT
* Home assessment
* Eye check
80
What are some complications of a fall (4)?
* Fracture (esp **HIP**)
* Subdural haematoma
* Rhabdomyolysis
* Pneumothorax
81
What is rhabdomyolysis?
Muscle breakdown and release of contents into bloodstream
82
What is rhabdomyolysis common after a fall?
Trauma
83
What are some risk factors for rhabdomyolysis (2)?
* Steroid use
* Hyperthermia
84
What are the signs/ symptoms fo rhabdomyolysis (2)?
* Muscle pain
* **Coca-cola urine**
85
What blood results would be suggestive of rhabdomyolysis (3)?
* Raised creatinine kinase
* Raised myoglobin
* Hyperkalaemia
86
How is rhabdomyolysis treated (2)?
* IV fluids
* IV sodium bicarbonate
*to prevent AKI*
87
What medications commonly cause falls in elderly (6)?
* BP meds
* Nitrates
* Anticholinergics
* Antidepressants
* Benzos
* Opiates
88
What are the criteria for a diagnosis of postural hypotension (3)?
* Drop in **20mmHg** or more union standing - **systolic BP**
*or*
* Drop in **10mmHg** or more upon standing - **diastolic BP**
*within 3 minutes of standing*
89
What is the pathophysiology of postural hypotension?
Impaired neuro-cardiac baroreceptor reflex + decreased BV plasticity --> blood pools in legs + low BP
90
What are some causes of postural hypotension (5)?
* Heart failure/ AF
* Autonomic dysfunction e.g. **diabetes**, **parkinsons**
* Medications (esp. BP meds)
* Alcohol
* Addisons
91
What are the signs/ symptoms of postural hypotension (5)?
* Lightheadedness
* Syncope
* Dizzy
* Palpitations
* Visual changes
92
How should postural hypotension be investigated (3)?
* **L/S BP**
* ECG
* Bloods
93
How should postural hypotension be managed (3)?
* Conservative = stand slowly, increased water intake
* Midrodine (alpha 1 agonist)
* Fludrocortisone (aldosterone)
94
What is the pathophysiology of a pressure sore?
Pressure --> reduced blood flow + friction --> erosion of tissues
95
What are the most common sites of pressure sores (2)?
Bony prominences (e.g.):
* **Sacrum**
* Heel
96
What are some risk factors for pressure sores (4)?
* **Immobility**
* Malnourishment + dehydration
* Incontinence
* Pain (causes lack of mobility)
97
What scoring system is used to classify the risk of developing pressure sores?
Waterlow score
98
What are the criteria for grading the different severities of pressure sores (4)?
1. Non blanching erythema + intact skin
2. Mucosal breach (only affecting epidermis/ dermis)
3. Full thickness skin involvement (can affect SC tissue)
4. Bone/ muscle/ joint involvement (through fascia)
99
How are pressure sores investigated (2)?
* Bloods
* Sore swab (MC&S)
100
How are pressure sores prevented (2)?
* Repositioning
* Barrier cream
101
How are pressure sores managed (4)?
* Pain ladder
* IV fluclox (if cellulitis suspected)
* Wound dressing
* Surgical debridement (grade 3/4)
102
What is malnutrition?
Nutritional defect with functional/ biological effects
103
What are some risk factors/ causes for malnutrition (6)?
* Older age
* Eating disorders
* Malabsorption (e.g. IBD, crohns)
* Poor diet
* Dysphagia (e.g. stroke)
* Cancer
104
How can the risk of malnutrition be screened for?
MUST (malnutrition universal screening tool)
105
What are the 3 criteria in the MUST tool?
* BMI
* Unintended weight loss
* Likely to not be able to eat properly for 5+ days
106
What do the different scores in the MUST tool mean?
* 0 = nothing
* 1 = observe
* 2+ = dietician review
107
What are the signs/ symptoms of malnutrition (5)?
* **Anaemia** (fatigue...)
* **Poor wound healing**
* **Dehydration**
* Constipation
* Reduced urine output
108
How is malnutrition investigated (3)?
* Bloods
* L/S BP
* ECG
109
How is malnutrition managed (4)?
* Fortispis + increase dietary intake
* Dietician review
* Enteral feeding methods
* Parenteral feeding
110
What would a dietician assess in a review (4)?
* Swallow
* Monitor electrolytes (reseeding syndrome)
* Advise diet
* Advise feeding method
111
What are the types of enteral feeding (3)?
* Nasogastric/ nasojejunal feeding
* Percutaneous endoscopic gastrostomy
* Percutaneous endoscopic jejunostomy
112
How long can a NG tube stay in for?
30-60 days
113
What is an paraenteral feeding method?
PICC feeding
114
What are some complications of malnutrition (5)?
* Osteoporosis
* Falls
* Refeeding syndrome
* CV (bradycardia, arrhythmias)
* Poor immunity
115
What is osteoporosis?
Reduced bone mineral density
116
What is the diagnostic criteria for osteoporosis?
Femoral head BMD < -2.5 on DEXA scan
117
What causes osteoporosis (9)?
* **S**teroids
* **H**yperthyroid/ parathyroid
* **A**lcohol + smoking
* **T**hin
* **T**estosterone (low)
* **E**arly menopause
* **R**enal/ liver failure
* **E**rosive bone disease (e.g. RA)
* **D**rugs
118
What drugs commonly cause osteoporosis (other than steroids) (3)?
* AEDs (e.g. phenytoin)
* PPIs
* SSRIs
+ steroids obviously
119
How is osteoporosis investigated (2)?
* Bloods
* DEXA scan
*X-ray to look for fractures*
120
What does the T-score compare the BMD to?
Healthy 30 year old
121
What is the Z score?
BMD compared to average for same demographic
122
What are the different T-scores suggestive of? (3)
* > -1 = normal
* -2.5 --> -1 = osteopenia
* < -2.5 = osteoporosis
123
What score assess the risk of people with osteoporosis?
FRAX score
124
What specific risk does the FRAX score assess?
Risk of major osteoporotic fracture in next 10 years (in 40-90 year old)
125
What are the different risk categories according to FRAX score (3)?
* < 10% = low risk --> follow up
* 10-20% = medium risk --> DEXA scan
* > 20% = high risk --> treat + DEXA
126
How is osteoporosis managed (5)?
* ADCAL D3
* **Bisphosphinates** = 1st line
* Denosumab
* Raloxifene
* HRT
127
When should a patient be immediately started on osteoporosis meds without the need for a DEXA scan?
**Fragility fracture** in patients **over 75**
128
What are two options for bisphosphinates?
* PO alendronate
* IV zoledronate (yearly)
129
How should oral alendronate be taken?
* **Empty stomach** (30 min before or 2 hour after food)
* **Stay sat** for 30 minutes
* Take with a **glass of water**
130
What are two side effects of alendronate (2)?
* Gord
* Osteonecrosis of the jaw
131
How does Denosumab work?
Inhibits RANK-L
*RANK-L increases osteoclasts activity and decreases osteoblast activity*
132
How does raloxifene work?
Oestrogen agonist at bone (inhibitor at endometrium)
133
What is incontinence?
Involuntary enuresis
134
What are the types of incontinence (5)?
* Urge/ overactive bladder
* Stress
* Mixed
* Overflow
* Functional
135
What are the features of urge incontinence (2)?
* Key in door syndrome
* Nocturnal Sx
136
What triggers stress incontinence?
Valsalva manoeuvres
137
What is overflow incontinence?
Lower urinary tract obstruction e.g. BPH --> post void retention --> unexpected leaks
138
What are some risk factors for incontinence (9)?
* Female
* Multiparity
* Older age
* Abdo surgery
* BPH
* Spinal trauma (neurogenic bladder)
* Constipation
* Medications (e.g. diuretics)
* Ketamin use
139
How is incontinence investigated (5)?
* Bladder diary
* Vaginal exam
* Urine dip
* Urodynamics
* Imaging?
140
How is urge incontinence treated (3)?
* Bladder retraining (6 weeks)
* Oxybutynin (antimuscarinics)
* Mirabegron (for older people - not anticholinergic)
141
How is stress incontinence treated (3)?
* Pelvic floor exercises (for 3 months)
* Surgery
* Duloxetine
142
What are the two types of urine retention?
* Acute
* Chronic
143
What is acute vs chronic urine retention in terms of volume?
* Acute > 600ml
* Chronic 1000-1500ml
144
What are some causes of urinary retention (3)?
* BPH/ prostate cancer
* Anticholinergics, TCAs, opioids
* Faecal impaction
145
How is urinary retention investigated (4)?
* Urinalysis
* PR exam (for faecal impaction/ enlarged prostate)
* Bloods
* USS bladder
146
How is urinary retention treated (2)?
* Catheterise
* Analgesia
147
What are 3 complications of urinary retention?
* Hydronephrosis
* Pyelonephritis
* AKI
148
What time period does palliative care usually refer to?
Less than 3 months left to live
149
What are the principles of palliative care (4)?
* Maximise QOL
* Set affaris in order (e.g. will)
* Address spiritual needs
* Look after family
150
What is often first line for pain in palliative care?
Morphine/ other opioids
151
What are some examples of opioids other than morphine (4)?
* Codeine (50% oral bioavailability)
* Tramadol
* Oxycodone
* Diamorphine
152
What is first line for agitation in palliative care?
Haloperidol
*when terminal = midazolam*
153
How are secretions treated in palliative care (2)?
* Hyoscine
* Glycopyrronium
154
What is first line for N+V in palliative care?
Metoclopramide
155
How is dyspnoea treated in palliative care (3)?
* Opioids
* Midazolam
* O2
156
How can medications be delivered in palliative care if patient is unable to take them orally?
Syringe diver
157
What is hypothermia?
Core temperature < 35
158
What are the signs/ symptoms of hypothermia (5)?
* Shivering
* Cold + pale skin
* Slurred speech
* Tachypnoea + tachycardia
* Confusion
159
How should hypothermia be investigated?
* Take temperature
* ECG
160
What might an ECG show for those with hypothermia?
Osborn-J waves
*small humps at end of QRS*
161
How is hypothermia treated (3)?
* ABCDE
* External reheating
* Warm IV fluids
162
What is considered hyperthermia?
Core body temperature > 40
163
Who is typically affected by hyperthermia (2)?
* Young patient due to exertion
* Older patient due to temperature
164
What are the signs/ symptoms of hyperthermia (6)?
* Tachycardia
* Hot flushed skin
* AMS + confusion
* Muscle cramps
* Seizures
* Hypotension
165
How should hyperthermia be investigated (3)?
* Take temperature
* ECG
* BP
166
How is hyperthermia managed (3)?
* ABCDE
* IV fluids
* COOLING
167
What muscles are commonly affected by nocturnal cramps (2)?
* Claf
* Feet muscles
168
How can nocturnal cramps be treated?
Quinine
*SE = ECG changes, hypotension, metabolic acidosis*
169
What care packages can the NHS provide (4)?
* Home apparatus (e.g. handrails, ramps)
* Allowances (e.g. PIP, attendance allowance)
* Carers up to 4 times per day
* Continued NHS healthcare (e.g. palliative care)
