Geriatrics Flashcards
(123 cards)
1
Q
common geriatric syndrome
A
incontinence, confusion, falls( high order function)
2
Q
what cause reduced organ reserve( reduce ability to response to physiology stress)
A
- aged related changes
2. disease related changes
3
Q
difference in elderly
A
reduced thermoregulation, cognitive reserve, postural instability, cardiac reserve, resp reserve, glucose intolerance, immune responses
4
Q
pharmacokinetics changes in elderly
A
hepatic and renal clearance, little change of VD, increased T1/2, slower absorption
5
Q
drug absorption changes?
A
delayed gastric emptying, slow transit time, increase PH( gastric congestion reduce absorption of diuretics, and PPI affects VB12 absorption)
6
Q
drug metabolism changes
A
reduce hepatic size and hepatic blood flow
drug hepatic-ally metabolised has long T1/2
7
Q
drug has longer T1/2 in the elderly due to liver changes?
A
lignocaine, propranolol, warfarin, barbiturates, verapamil, chlormethiazole, quinine
8
Q
increase bio-availability of drug?
A
nortiptyline, metoprolol, diazepam
9
Q
more drug and drug interaction in elderly?
A
paracetamol and warfarin
PPi and clopidogrel
10
Q
drug excretion changes?
A
renal clearance decreased with ageing
11
Q
renally excreted drug clearance reduced( require small dose), the drug include?
A
digoxin cephalexin morphine aminoglycosides pethidine lithium
12
Q
what drug renal excretion enhanced in elderly
A
diuretics
trimethoprim, ACEI, spironolactone
13
Q
what is triple whammy acute renal dysfunction
A
ACEi, NASIDS, and diuretics
14
Q
how dose decreased albumin affects drug dose
A
higher free drug concentration( more toxicity esp digoxin) but total concentration to be measured is normal
15
Q
body compartment
A
fat content increase, tissue volume stable, intracellular water drop, albumin drop
( shorter, fatter, drier, less muscly)
16
Q
larger VD OR longer T1/2 for lipid soluble drug
A
diazepam
17
Q
water soluble drug increased serum levels
A
digoxin and paracetamol
18
Q
decreased muscle, shorter, surface area changed
A
chemotherapeutics agent prescription based on surface area
19
Q
phrarmodynamic change
A
beta receptor down regulated
larger baroreceptor response ( risk of hypotension)
20
Q
altered cerebral auto regulation( shift in range of MAP regulation)—> increase orthostatic hypotension
A
more resistant to Hypertension but more sensitive to low BP
21
Q
why elderly have altered volume regulation( less able to maintain volume)
A
reduced renin and aldosterone, salt wasting, increase ANP, loss of thirst sense
22
Q
systole dysfunction in elderly
A
cardiac muscle becomes stiff, restricted ventricular filing during diastole
23
Q
ADR of diuretics?
A
dehydration, hyponatremia, falls
24
Q
ADR of CCBs
A
oedema, falls
25
ADR of statins
muscle pain, rhabdomyolysis, ARF
26
ADR of amiodorone
thyroid, lung, taste alteration
27
ADR of verapamil
constipation
28
class 1 anti- arrhythmic
fall confusion
29
ADR of NSAIDS
oedema, ARF, CCF
30
ADR of atypical antipsychotics
stroke and CVD
31
high use of what drugs in elderly?
Psychotropics, hypnotics, sedatives, laxatives , CVS drug, OTC
32
effects of poly pharmacy?
increased ADR, drug interaction, noncompliance, complicated drug regimen, confusion and unreliable history
33
high risk drugs in elderly
anticholinergic drug( confusion , constipation risk0: anti-psychotropics, anti-depressants, antihypertensive ( increase risk of fall): diuretics, digoxin( narrow therapeutics window), narcotics,CNS acting drugs causing sedation ( antihistamine, Benzo, NSADIS, narcotics, stemetil
34
medications causing falls
```
central acting, anti-HTN
benzo, antidepressant, antipsychotics, anti-HTN, anti-arrhythmic class 1( low dose, short time)
```
35
paucipharmacy condition
pain, HF, IHD, OP, AF
36
common error ( anti-HTN, sedative, anticholinergics)
- Oral hypoglycaemia: Increase mortality and falls
- Metformin in renal impairment
- Cox2 or NSAIDS with known heart or renal failure
- Develop oedema reduce plasma volume--> risk of hypotension and fall ( use compression stocking)
- Prescribe narcotic but not think of constipation ( treat pre-emptively)
-Cox2 or diuretics affect lithium clearance
- Use anti-cholinergic drug (e.g. also digoxin) in confusion patient
-Verapamil not in pt with constipation
-Undetected postural hypotension ( change to do postural bp)
Failure to adjust dose in real impairment
37
diagnostic criteria of major neurocognitive disorder (DSM-V)
1. evidence of cognitive decline
2. infers with independence in DAL
3. not due to delirium
4. not explained by another mental disorders
38
mild cognitive impairment= minor NCD
1. subjective cognitive concern or by relatives
2. reduce 1-2SD below
3. precursor for dementia,( better or the same)
39
Screening tool for dementia?
MMSE, MOCA, RUDAS, KICA, ACE
40
aspects of screening tool?
memory, orientation, judgment and problem solving, community affairs, home ad hobbies, personal care
41
types of dementia?
1. alzheimer's disease
2. vascular dementia
3. Lewy body dementia
4. frontal temporal dementia
5. alcohol
42
how to treat dementia?
advance care planing, risk factors modification
1. cholinesterase inhibitor( Donepezil for AD MMSE>10)
2. memantine( NMDA receptor, for severe AD mmse10-14)
3. SSRI/SNRI
43
what is BPSD( Behavioural and psychological symptoms of dementia) =responsive behaviours
symptoms of disturbed perception, though content, mood, and behaviours frequently occurs in pt with dementia
44
behavioural symptoms in BPSD?
```
vocally disruptive behaviours
agitation
wandering
aggression
apathy
hoarding
sexual disinhibition
culturally inappropriate behaviour
```
45
psychological symptoms in BPSD
```
depression
anxiety
hallucination
delusions
sleep disturbance
```
46
consequence of BPSD
```
cognitive impairment
increased vulnerability stress-or
unmet need( sleep, sleep)
pain
QOL, greater hospitalisation early institutionalisation
caregiver burden
```
47
how to rate BPSD
Tier 1-7 ( common.y 4-5 in hospitalization)
48
1st line in mx BPSD
Non-pharmocologically strategies
49
patient factors contribute to BPSD
1 pre-morbid personality/ psychiatric illness
2 acute medical problem ( UTI, pneumonia, dehydration, constipation)
3 unmet needs( pain, sleep, fear, boredom, loss of control or purpose)
50
modifiable proximal factors in needs-driven dementia compromised behaviours (NDB)
physiological needs
psychological need
social environmental
physical environment
51
background factors in NBD
neurocongnitive factors
general health
personal characteristics
demographics
52
two models to explain BPSD (stress, unaddressed need)
1. NDB: needs-driven dementia compromised behaviours
| 2. PLST: progressively lowered stress threshold
53
PLST means?
stress threshold lowered
environmental demands exceed a person ability to cope-->impaired function and behavioural symptoms
stressor accumulate during the day and pt can cycle between anxious and impaired function
need reduction of stress through intervention to diminish anxious behaviour and prevent impaired functioning
54
assessment tool for syndrome of dementia?
```
CMAI, RAWS-CD
cornell depression scale
geriatric Depression scale
NPI (neuropsychiatric inventory)
behave-AD
```
55
3 important foci for assessment and evaluate behaviours
antecedent( triggering events)
2. behaviours( description of behaviours
3. consequence( happen afterwards)
56
how to treat BPSD
1. Address unmet needs (NBD)
2. non-pharmacological strategies( address environmental precipitants, physical precipitants, psychological precipitants)
3. sedation if extreme distress
4. 12 wk anti-psychotropics drug
57
how to address under-treated pain in dementia
analgesic trails
| self report if MMSE>19 using visual analogue an faces scale, simple verbal or numerical scales( recommended)
58
damage to pain processing networks in dementia
1. sensory discriminative
2. motivation affective
3. behavioural responses
white matter lesion causing chronic neuropathic pain causing allodynia and hyperalgesia
59
PAINAD scale
1, breathing independent of vocalisation
2. negative vocalisation
3. facial expression
4. body language
5. consolability
60
pain management in dementia
paracetamol, opiates, adjuvants pregabalin
61
constipation treatment in dementia
bulking forming agents, stool softeners, osmotics, stimulants, enemas
62
cholinergic toxicity
sedation, confusion, cognitive decline, hallucination
63
anti psychotics in dementia
start low go slow( review at 12 wk)
- cause akathesia
- C/I for true psychosis, hallucination and delusion
- haloperidol,risperidone, olanzapine, quetiepine
64
anti psychotics side effect
neuroleptic sensitivity in lewy body dementia
increased risk of stroke and CVS if long term use
increased risk of falls, EPSE, tardive dyskinesia, long QT, stroke and death
respiratory depression , sedation
65
medications in dementia
anti-psychotics, anticonvulsants, antidepressants, cholineraserase inhibitor
66
what causes incontinence in general
reduced bladder capacity
| atrophy of tissue post menopausal
67
why micturition is high order function
involves cortex, pons, spinal cord, peripheral autonomic, somatic and sensory afferent innervation of lower urinary tract
68
contience depends on
integrity of lower urinary tract system
| adequate mentation, mobility, motivation and manual dexterity
69
incontinence a manifestation of
urological disease
neurological disease
gyn disease
70
why continence happens in elderly
```
cognitive impairment
poor mobility
heart failure
prostate enlargement
oestrogen deficiency
increased detrusor involuntary contractions
change in ADH secretion so nocturia
```
71
incontinence more common in M or F
F
72
effect of incontinence
```
Social Effects
• social embarrassment because of odor
• social withdrawal
• stress on carer
• Mood changes
• early institutionalisation
```
```
Physical Effects
• Skin excoriation
• Skin infection
• Pressure ulceration
• Urinary Tract Infection
• Sleep deprivation
• Falls and fracture
```
73
types of incontinence
• stress (eg wetting with activity)
• urgency (eg wetting when unable to reach
bathroom in time)
• overflow (eg constant wetness without the urge
to void)
• sphincteric (eg loss of urine with upright posture)
• spasticity of an obstructed bladder overcoming cortical
control
74
stress incontinence causes
mechanical problem with weak pelvic floor structure, intrinsic sphincter deficiency( when intra-vesicle pressure> urethral pressure)
75
urge incontinence ( most common) causes
detrusor instability/ over-activity
| detrusor hyperreflexia if SC above S2
76
overflow incontinence
obstrunction duet o BPH,
| atonic bladder due to DM, alcoholics, SC below S2
77
how is urine volume in each incontinence
stress: small
urge: large
overflow: small dribbling
78
how to treat each incontinence
stress: pelvic floor exercise
urge: alpha agonist. bladder relexant ( anti-cholinergic, TCA, oxybutynin)
stress: remove obstrunction, finisteride, caterization
79
what drug precipitates each incontinence
urge: diuretics, caffeine, sedative, hypotics, alcohol
overflow: anticholinergic, alpha agonist, nacrotics, CCB
80
Neuro related cause of incontinence
```
Lesions above S2
produce detrusor
hyperreflexia
• Lesions below S2
produce detrusor
areflexia
```
81
Aggravating Condition of incontinence
```
Acute medical illness
• Rectal loading
• Delirium
• poor mobility
• stroke
• arthritis
• hip fracture
• pneumonia, CCF
• Depression
• Dementia
• Diabetes with
hyperglycemia
• Obesity
• alcohol excess
• Drugs
```
82
what drug induces incontinence
hypnosedatives-->Excessive sedation
diuretics-->Frequency, urgency
Alpha blockers -->Bladder neck relaxation
anti-depressants-->constipation
Major Tranquillizers-->constipation, confusion
Analgesics -->constipation
Anti-hypertensives-->postural hypotension
NSAID’s-->Frequency, urgency
83
Functional Incontinence
```
• Environmental
• sedatives/ hypnotics
• physical mobility or
access problems
• drugs inducing diuresis
```
84
Neurological causes of incontinence
* dementia
* Stroke
* Muscle weakness
* Parkinson’s Disease
* peripheral neuropathy
* diabetes
* alcohol
* spinal cord injury
* Multiple sclerosis
* Brain Tumour
* Head Injury
* Hydrocephalus
85
normal pressure hydrocephalus triad
dementia, gait disturbance, and urinary incontinence.
86
Transient Cause for
| UI
Delirium or other confusional state
• Infection
• Atrophic urethritis or vaginitis
• Drugs: diuretics, anticholinergics, opiods, alpha
blockers in women, alpha agonists in men, Ca
channel blockers
• Psychological, severe depression
87
Detrusor Instability
Commonest cause of incontinence in elderly
• usually assoc with strong sense of urgency
• uninhibited bladder contractions
• if assoc with CNS disease labelled Detrusor hyperreflexia
• may be assoc with impaired bladder contractility in the elderly
88
Urge Incontinence:
• Detrusor overactivity and uninhibitable bladder
contractions cause leakage
• Patient may describe sudden sensation of urgency
to void then involuntary loss of urine
• Voiding reflex is initiated when bladder volume is
well below capacity
• Associated with frequency due to small voiding
volumes
89
Drugs contributing to urge
| incontinence:
* Diuretics
* Caffeine
* Sedative-hypnotics
* Alcohol
90
Drugs contributing to overflow
| incontinence:
```
• Anticholinergics
Calcium channel blockers
• Alpha-adrenergic agonists
• Beta-adrenergic blockers
Antidepressants
• Antipsychotics
• Sedative-hypnotics
• Antihistamines
• CNS depressants
• Narcotics
• Alcohol
```
91
Atonic Bladder
* diabetes
* alcoholic neuropathy
* sacral spinal cord lesions below S2
* drugs blocking bladder contraction
92
Neurogenic
association with other neurol disease
Either idiopathic or caused by sacral LMN dysfunction
Leads to high post void residuals
• Mainstay of management is self-catheterisation
93
Stress incontinence: situational involuntary loss of urine with
• lifting, coughing,laughing,running
94
anatomical problem in stress incontinence
often due to loss of urethrovesical angle with descent of
| bladder neck into pelvis
95
Ix for stress incontinence
• Marshall or Bonney test shows control of stress incontinence
when bladder elevated manually by the examiner
96
Pelvic floor excercises
for stress incontinence
| for urge incontinence
97
drug for incontinence
• Anticholinergics, including tricyclic
antidepressants, relax the bladder and increase
its capacity
• Elderly people more sensitive to adverse effects
such as blurred vision, dry mouth, GOR,
constipation and confusion
98
Oxybutynin
Nonselective antimuscarinic agent that relaxes
| bladder muscles and has local anaesthetic activity
99
atonic bladder tx
muscarinic agonist Bethanechol
100
Outlet obstruction tx
α₁-blocker: prazocin
101
Stress incontinence drug tx
oestrogens -topical
102
Two principles of Bladder Retraining
1. Frequent voiding to keep the volume of urine in the
bladder low
2. Retraining of the CNS and pelvic mechanisms to
inhibit detrusor contractions
103
Kegel exercises
learned skill of muscle
contraction and relaxation that reduces urinary
incontinence by producing urethral closure by
contraction of the periurethral and other pelvic
muscles
104
why does women live longer( tho higher disability than man)
1. biological( oestrogen protective against CVD), T4 Causes immunosuppresion, longevity enhancing genes on X chromosome
2. social and behavioural factors
( risk, healthcare, nutrition)
105
why do women have poorer health status
more susceptible to chronic il, high risk of depression and anxiety, high prevalence of dementia( mitochondria protected against amyloid beta toxicity in younger, education and exercise)
childbirth impact
106
theory of ageing
complex system with lots of redundancy has higher rate of failure but still higher reserve
107
what is frailty
a state of increased vulnerability to stressor
| reduced physiological reserve and ability to compensate for homeostasis disruption
108
frailty has increased risk of
disability, institutionalisation and death
109
3 main approaches to measure frailty
1. clinical syndrome and phenotype
2. subjective option ( checklist of age ass changes in appearance, combination and mobility)
3. multidimensional risk state
110
frailty using fried phenotype include ( not consider depression , cognition and performance based)
3 or more of
1. unintentional weight loss
2. self reported exhaustion
3. weak grip strength
4. slow walking speed
5. low physical activity
111
what measure to you need under subjective option (limited generality and rely on judgement)
clinical frailty scale
112
multi-dimensional risk states means
measure quantity when various deficits accumulate during the life( person becomes more frail)
113
what is deficits in deficits accumulation
symptoms, signs, disease, disability, abnormal lab measurement
accumulate with age, ass with AE, do not saturate, cross different domains, using the same item
114
how to measure deficits accumulation
frailty index
115
what is frailty index
construct from different numbers and the off variables
| define risk of adverse outcomes ( than phenotype definition)
116
complex system= older person redundancy has been lost, what function fails first
high order function
upright bipedal ambulation
divided thinking
117
frailty predict what and not what
predict mortality
| not predict hospital readmission
118
CAM sampled DSM 5 for delirium dx
1. acute change and fluctuate in mental state and hehaviours
2. inattention
3. disorganised thinking
4. altered consciousness ( not alert)
119
how to assess depression in elderly
geriatric depression scale( GDS)
120
Presentation of depression in late lif
§ No-sadness depression:
| □ irritable, multiple complaints ( underlying mood problem can cause the presentation)
121
Treatment of delirium
Neuroleptics
| Benzo is only tx if alcohol withdrawa
122
Delirium aetiology
§ Pre-exposing factors RF:
Old age, Male, lots of medication, severe illness ( UTI, pain, fracture)
Frailty: More fragility, more likely to have delirium
Pre-morbid cognitive impairment or dementia : limited cognitive reserve( new precipitating factors will make them more likely to delirium)
Precipitating factors
Look infection : UTI, chest infection, skin infection, IE, meningitis
Electrolytes : Na( hypoNa know chronic or acute, need to have significant drop acutely ), Ca( hyperCa)
Alcohol: alcohol withdrawal cause DT
123
Types of delirium
Active psychomotor
hypoactive
mixed
