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Flashcards in Geriatrics Deck (85):

A 78 year old woman presents with incontinency associated with coughing. What type of incontinency is it likely that she has?

Stress incontinence - 50% of post-menopausal women will have this to some degree


A 75 year old gentleman presents with stress incontinence and you notice from his notes that he has had surgery recently. What procedure is it likely he has undergone?

prostatectomy - can cause stress incontinence in males


What muscles might have been damaged in a mother of two who presents with stress incontinence?

pelvic floor muscles - damaged in childbirth leading to stress incontinence.


A 35 year old woman presents with optic neuritis and diplopia which gets worse when she exercises. What type of incontinence is she at risk from?

overflow incontinence - patient has MS and as condition worsens may affect the signals from the bladder that communicate how full it is.


In a gentleman with incontinence due to prostatic hyperplasia, give one class of drug you might prescribe and one class of drug you would not prescribe.

He will have overflow incontinence therefore prescribe alpha-blockers e.g. doxazosin, tamsulosin
Do not prescribe anti-cholinergics, these make symptoms worse and are for urge incontinence e.g. tolterodine


A patient with myasthenia gravis presents with urge incontinence, which class of drugs typically used to treat this condition is contraindicated?

Anticholinergics e.g. oxybutinin or tolterodine.
Consider B3 adrenergic agonist.


Give some examples of LUTs you might ask about in a 71 year old gentleman who presents with incontinence?

urgency, frequency, flow, nocturia, pain, hesitancy, flow, incomplete voiding, post-micturition dribbling, straining, spraying.


You wish to prescribe tamsulosin to a gentleman with overflow incontinence. What is an important contraindication to take into consideration?

Postural hypotension - side of alpha blockers which may be made worse so don't prescribe in these patients.


Give a cause of functional incontinence.

Patient has mobility issues or is in unfamiliar surroundings so can't reach toilet in time.


A patient presents with significant post-micturition dribbling. Which of the following is the most likely cause?
C. Myasthenia Gravis
D. Coughing
E. Dementia

Answer = B, patient has overflow incontinence

A: UTI causes urge incontinence
C: not a typical cause of incontinence
D: coughing may cause stress incontinence
E: may be a cause of urge incontinence as no longer any control over micturition pathways


Give 3 risk factors for incontinence.

Pick 3 from...
Childbirth, hysterectomy, obesity, menopause, caffeine/alcohol intake, diuretics, tricyclic anti-depressants, age, pregnancy.


Define urge incontinence.

a sudden, intense urge to urinate followed by an involuntary loss of urine.


Define stress incontinence.

Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.


Define overflow incontinence.

Involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate


Which of the following is a cause of urge incontinence?
C. Kidney stones
D. Parkinsons
E. All of the above

D. Parkinsons, may cause loss of control over micturition pathways.

A, B and C are causes of overflow incontinence


What are the two primary causes of overflow incontinence?

urethral strictures: due to enlarged prostrate, bladder stones, kidney stones
detrusor weakness: due to reduced signals about fullness of bladder e.g. in MS or diabetic autonomic neuropathy


Which of the following is an appropriate examination to carry out in a patient with new-onset incontinence?
A. abdominal exam
B. PR exam
C. urine dipstick
D. neurological exam
E. all of the above

E. all of the above

A: checks for a distended bladder
B: checks for constipation and prostatism (if male pt.)
C: checks for UTI
D: checks for MS, Parkinson's, stroke


A female patient with a 4 day history of incontinence gives a urine sample for a dipstick. It gives the following results...
Leukocytes: +
Nitrites: ++
Blood: +
Ketones: normal
Glucose: normal
What is the most likely cause of her symptoms from these results? What type of incontinence will she have?

UTI leading to urge incontinence
Raised nitrites indicates presence of bacteruria, blood is also a marker of infection. Leukocytes show pyuria.

n.b. Leukocytes are not always raised in UTIs in women as may have a low bacterial count UTI therefore do not exclude this diagnosis automatically.


Define dementia.

A progressive global decline in cognitive function without impairment of consciousness.


Define delirium.

An acute fluctuating disturbance in level of consciousness, attention and global cognition.


Which of the following might you include in a delirium screen?
A. Urinalysis
B. B12 + folate levels
C. Chest x-ray
D. Ferritin
E. All of the above

Delirium screen...
U+E, FBC, Creatinine, CRP, glucose, B12+folate, ferritin, LFTs, TFTs.
Chest x-ray, urinalysis, ECG, CT head (if indicated)


A 75 year old woman presents with a 3 day history of increasing confusion. When you see her she has impaired attention span and fluctuating level of consciousness.
Is she suffering from delirium or dementia?

Acute onset, low attention span and impaired consciousness.


A patient with a MMSE of 9 is referred to the memory clinic. Is there anything that they can prescribe in this case?

No. Medications indicated for an MMSE over 12 (or between 10-20 depending on what text you read)


Give an example of an acetylcholinesterase used in the treatment of Alzheimer's .

Donezepil, Rivastigmine, galantamine


A patient whose mother has just been diagnosed with Alzheimer's comes to see you. She is worried about her risk of developing the condition, which gene mutation might you test for?



Which type of dementia might have a sudden onset and step-wise deterioration?

Vascular dementia


Give 3 practical steps that can be taken in the treatment of a patient with dementia.

Care-coordinator, establish LPA/advanced directives, develop routines, try to avoid moving house/care home in the later stages of the disease, respite services for carers, avoid drugs which reduce cognition, memory books, label cupboards, organise medications


Which of the following drugs would be innappropriate to prescribe in someone with dementia?
A. paracetamol
B. Donezepil
C. Amitriptyline
D. memantine
E. All of the above

TCAs can reduce cognition and so make symptoms worse.


Which of the following types of dementia classically causes visual hallucinations?
A. Lewy Body
B. Alzheimer's
C. Vascular
D. Pick's
E. All of the above

A. Lewy Body dementia, classically causes visual hallucinations which then may develop into Parkinsonism


Which of the following types of dementia classically causes disinhibition and personality changes?
A. Lewy Body
B. Alzheimer's
C. Vascular
D. Pick's
E. All of the above

D. Pick's aka Fronto-temporal dementia


Which of the following types of dementia will often present initially with short term memory loss and visuo-spatial problems?
A. Lewy Body
B. Alzheimer's
C. Vascular
D. Pick's
E. All of the above

B. Alzheimer's.
While can appear in all types dementia, they are classical early symptoms of Alzheimer's.


A person must be assumed to have capacity until proven otherwise. True or False.

True - this is one of the five key principles of the Mental Capacity Act, 2005.


A person lacks capacity if they are unable to...

A. Understand the information relevant to the decision;
B. Retain the information;
C. Use or weigh the information;
D. Communicate the decision (by any means)
E. All of the above.

E. All of the above.
This are the four things needed for an individual to prove they have capacity


When does a person lack capacity under the Mental Capacity Act, 2005?

'if, at the time the decision needs to be made, he or she is unable to make a decision because of an 'impairment of, or a disturbance in the functioning of the mind or brain'


Does an LPA automatically have power over decisions relating to life-sustaining treatment?

No. It has to be explicitly stated that this is in their remit.


Which of the following criteria makes an advance directive binding on doctors?
A. The patient is over 16
B. It specifies the treatment to be refused and when this applies.
C. The person has capacity when the decision is to be enforced
D. The patient has appointed an LPA for property and affairs
E. All of the above.

An advanced directive is only binding if...
-The person making it was 18 or older and had the necessary capacity;
-It specifies the treatment to be refused and the circumstances in which the refusal is to apply;
-The person has not subsequently appointed an attorney to make the decision;
-The person has not done anything clearly inconsistent with the directive;
-The person does not have capacity at the time the decision has to be enforced


A patient with dementia has indicated to the nurse caring for her that they do no wish for anymore life sustaining treatment. If it is required, what should the doctors do?

Perform the life sustaining treatment until the patients wishes can be firmly established through an LPA or close relatives

An advance refusal will apply only to life-sustaining treatment where it is in writing, signed and witnessed and contains a statement that it is to apply even when life is at risk


An elderly patient with a known history of Alzheimer's presents to A+E in v-fib. She has an advanced directive that states she does not want reviving should she die in surgery. How should the doctors act?

They should perform life sustaining treatment as the advanced directive is not for the situation that the patient is in, and therefore is not valid.


A patient presents in respiratory arrest. He suffers from myasthenia gravis and has a written statement stating he does not wish to be revived in this situation. The statement is signed by only him, how should the doctors proceed?

The doctors should proceed with attempting life sustaining treatment as directives relating to this must be countersigned by a witness.


When should an IMCA be appointed?

When a decision needs to be made on behalf of an incapacitated adult in relation to either serious medical treatment or place of residence, and there is nobody close to the patient (who is not a paid carer) with whom to discuss it.


What is an IMCA

Independent Mental Capacity Adovcate


A patient with a history of delirium requires a PEG tube but a few days before they were found to lack capacity to make a decision unrelated to this. The attending doctor believes that they can insert the PEG tube based on this earlier assessment, is this correct?

No. An assessment of capacity must be made in relation to the particular decision that needs to be made at the time the decision is required.


A patient with liver cancer decides not to have major surgery which may save their life. One of the attending doctors questions if they have capacity given the nature of their decision. What is your response?

A person is not to be treated as unable to make a decision just because he or she makes an unwise decision (Key principle of MCA 2005)


An elderly patient with an expressive dysphasia and difficulty hearing following a stroke is asked about their treatment preferences however it is not clear whether they have understood. The doctors decide to make the decision for them, is this lawful?

No. A person is not to be treated as unable to make a decision unless all practicable steps have been taken to help him or her. In this case writing it down or finding someone trained in sign language may help.


An 84 year old woman presents to A+E having been found on the floor of her house. Her blood creatinine was found to be over 1000, what is likely to be happening and what should the management plan be?

Patient has rhabdomyolysis, treat for hyperkalaemia and give IV fluids to prevent AKI.


Give 4 causes of falls in the elderly.

Arrythmias, stroke, seizure, peripheral neuropathy, vasovagal syncope, intoxication, medications, infection, benign paroxysmal vertigo, environmental (trip and fall)


A 74 year old man presents having fallen over and hit his head in the garden 2 weeks ago. He now has fluctuating levels of conciousness. What are you most concerned about and what might your investigations show?

Subdural haematoma, CT will show a crescent shaped collection of blood over one hemisphere.


An 85 year old lady presents with a painful left hip. You suspect she has fractured it, what would clinical examination reveal?

Shortening and external rotation of her left leg.


Which of the following medications may cause postural hypotension?
A. Ramipril
B. Verapimil
C. Amitryptiline
D. L-dopa
E. All of the above

E. All of the above


In a lying and standing BP, what is considered a significant change?

SBP falls more than 20, DBP falls more than 10 from lying to standing.


A patient presents after a fall with high sodium and ketones in their urine.
What is this suggestive of?



You see an elderly patient in clinic who has had a couple of recent episodes of syncope. His medications are as follows.
Aspirin 75mg PO, OD
Metformin 500mg, PO, BD
Ramipril, 2.5mg PO, BD
Doxazosin, 1mg PO, OD
Amitryptiline, 75mg PO, OD
Atorvastatin, 10mg PO, OD
What medication changes could you suggest to try and stop these episodes from happening?

Change 1. Stop the ramipril as doxazosin is an alpha-blocker and licensed for treating hypertension.

Change 2. Swap amitryptiline for an SSRI such as citalopram as these do not have the same hypotensive side effects.


What kind of interventions can be made to prevent falls in the elderly?

Review medications to avoid postural hypotension
Ensure they are in familiar surroundings
Handles and aids around the home
Zimmer frame usage and walking sticks
Stair lifts
Assess footwear to make sure it is supportive (podiatry)
Physiotherapy to help improve balance and strength
OT assessment to identify areas to help


What is the purpose of intermediate care?

Shortens length of stay in hospital and allows for patients to be rehabilitated post-hospital to help them improve mobility and strength. Aim is to prevent readmission to hospital.


Give an example of a hospital acquired infection that can effect the elderly.

C. difficile, Norovirus, MRSA


Give 3 things which might delay an elderly patient's discharge from hospital.

TTOs not completed in time/prescription not completed
Hospital acquired infection
No bed in either care home or intermediate care
Therapy assessment in community delayed
No carers in place
Loss of muscle strength
Occupational therapy assessment identifies issues to be addressed in home e.g. alarm or handrails
Family resist the discharge plan
Safeguarding issues
Pressure sores


Give 3 members of the MDT involved in the care and discharge of an elderly patient.

Doctors, nurses, HCAs, admin staff, physiotherapists, occupational therapists, social workers, discharge nurses, pharmacists, transport services


Why might an elderly female patient be at higher risk of UTIs?

Anatomical risk.
Poor personal hygiene
Incontinence (bowel or bladder)
Catheter use
Recurrent UTIs
Lower oestrogen


Which bacteria are more commonly associated with UTIs in the residents of care homes?

Enterococci and Staphylococci are more common causes.


An elderly woman who lives at home presents with a 3 day history of incontinence with foul smelling urine. What is your initial course of action?

Start on trimethoprim or nitrofurantroin (check renal function). Encourage increased fluid intake.


In a patient with renal impairment and a UTI, which first line antibiotic is absolutely contraindicated?

Nitrofurantroin. Renal impairment leads to increased toxicity and reduced efficacy due to lower renal concentrations.


An elderly lady presents with signs of fever and increased confusion. Give the two major types of infection you would wish to investigate first.

UTI and pneumonia


An elderly gentleman has got a pressure sore on his sacrum which has the appearance of a clear blister. What grade of sore has he got?

PU grade 2
Grade 1: non-blanchable eythema of intact skin
Grade 2: partial thickness involving epidermis/dermis, may appear like a blister
Grade 3: Full thickness skin ulcer, may be covered in slough or necrotic tissue
Grade 4: deep enough to see bone, muscle and tendon underneath.


An elderly gentleman who lives at home presents with a chest infection, and scores 1 on a CURB65. What is the most appropriate course of treatment?

Oral amoxicillin or clarithromycin.


An elderly lady who has been in hospital recovering from a broken hip presents one morning with pyrexia and consolidation of her right lung base. Which antibiotic is most appropriate in this case?

IV aminoglycoside (e.g. gentamicin) plus a cephalosporin (e,g. cefuroxime) or an anti-pseudomonal penicillin (both IV).
Treatment for a hospital acquired pneumonia (Oxford Handbook)


An 87 year old lady presents from a care home with a 4 day history of a productive cough, pyrexia and confusion. She has a respiratory rate of 31 and has a blood pressure of 87/65.
What is her CURB score and what is the best course of treatment?

CURB of 4, therefore has a severe, community acquired pneumonia. Admit to ICU/HDU.
Administer co-amoxiclav or cephalosporin IV AND clarithromycin IV along with oxygen and fluids.


A 74 year old man who recently suffered a stroke has reduced breath sounds over his right lung and consolidation in the lower lobe. What is the likely cause and how is it treated?

Aspiration pneumonia.
Treat with Cephalosporin IV and metronidazole IV


An elderly patient on the ward has contracted a seasonal strain of influenza. What is the appropriate course of action?

Isolate in a side room and commence barrier nursing. Do not discharge until symptom free for a few days.
Treat with tamiflu PO or IV aciclovir if not tolerated. Support with fluids if needed.


An elderly patient with dementia is admitted having been diagnosed with a UTI 4 days ago. She was given oral trimethoprim to take but is now complaining of loin pain and appears feverish. Why might her symptoms have worsened, what is might you suspect now and how would you treat it?

Not taken antibiotics as prescribed, possibly due to dementia.
Suspect pyelonephritis. Treat with IV cefuroxime or ciprofloxacin until symptoms improve.


Which bacteria causes the largest proportion of UTIs and what is the first line antibiotic used?

E. coli, trimethoprim


An elderly gentleman with a longstanding history of kidney stones is admitted with a UTI. Should it be considered complicated or uncomplicated? Justify your response.

Complicated due to the history of kidney stones and the fact he is male.


Why might an elderly gentleman with BPH be at a higher risk of a UTI?

Obstruction of urine outflow leading to stasis and therefore increasing risk of a UTI


Which of the following bacteria is a common cause of pneumonia in the elderly but not in the young?
A) S. pneumoniae
B) S. aureus
C) H. influenzae
D) Legionella
E) C. pneumoniae

C) H. influenzae


Which of the following bacteria is a common cause of pneumonia in the elderly following a viral infection?
A) S. pneumoniae
B) M. pneumoniae
C) H. influenzae
D) Legionella
E) C. pneumoniae

A) S. pneumoniae
Also S. aureus but not as common as above. All viral infections will pre-dispose the elderly to a pneumonia to some degree if in the respiratory tract.


An elderly patient presents with a pneumonia of their right lower lobe. What might you hear on auscultation?

- bronchial breathing on the right
- reduced volume of breath sounds over right lower lobe
- coarse, right basal crackles
- increased vocal resonance over right lower lobe
- pleural rub on right side


An elderly patient has recently recovered from a viral LRT infection. What might you be on the look out for?

A developing pneumonia, most likely due to S.pneumoniae


An 89 year old lady is admitted to A+E having collapsed in her home. She has a 5 day history of a dry cough which has recently begun producing rust colored sputum and is now tachyapnoeic. You diagnose her with a pneumonia, what is the most likely causative organism?

S. pneumoniae. Dry cough leading to cough producing rusty sputum and rapid shallow breathing are typical of an infection caused by this bacteria.


An elderly gentleman presents with confusion and a 2 day history of sharp, stabbing chest pain on inspiration. What is the most likely cause of his pain?

Pleuritic chest pain due to pneumonia.


You have just discharged a patient who was admitted to the ward with a pneumonia. What follow up would you request?

Chest x-ray at 6 weeks


You see an 87 year old lady on the ward who has become increasingly confused over the weekend since being admitted a week ago with a viral infection. You perform an MSU and this is negative for nitrites and leukocytes. What investigations might you perform next and why?

Investigate for pneumonia. Viral infection and hospitalization increase the risk of pneumonia. Confusion may be the only initial symptom of pneumonia in the elderly.
- FBC, U+E (esp. for urea), CRP, ESR
- Chest x-ray
- blood cultures
- Respiratory examination and O2 sats.


An elderly gentleman with CKD 4 presents with a community acquired pneumonia with a CURB65 of 1. You prescribe him clarithromycin PO, what must you ensure you do?
A colleague then suggests another antibiotic, which is this and do you need to take the same precautions?

Halve the dose. All adults with an eGFR <30 should have their dose of clarithromycin halved.

Amoxicillin. Dose should be reduced in those with severe renal impairment to reduce risk of crystalluria.


An elderly patient has an eGFR of 47ml/min/1.73m. What stage of CKD have they got?
A. 1
B. 2
C. 3A
D. 3B
E. 4

C. 3A

1 = >90
2 = 89-60
3A = 59-45
3B = 45-30
4 = 30-15
5 = <15


An elderly patient has an eGFR of 27ml/min/1.73m. What stage of CKD have they got?
A. 1
B. 2
C. 3A
D. 4
E. 5

D. 4

1 = >90
2 = 89-60
3A = 59-45
3B = 45-30
4 = 30-15
5 = <15


An elderly patient has an eGFR of 61ml/min/1.73m. What stage of CKD have they got?
A. 1
B. 2
C. 3A
D. 4
E. 5

B. 2

1 = >90
2 = 89-60
3A = 59-45
3B = 45-30
4 = 30-15
5 = <15


An elderly patient has an eGFR of 12ml/min/1.73m. What stage of CKD have they got?
A. 1
B. 2
C. 3A
D. 4
E. 5

E. 5

1 = >90
2 = 89-60
3A = 59-45
3B = 45-30
4 = 30-15
5 = <15