Geriatrics Flashcards
(102 cards)
1
Q
What type of history is key when dx cognitive impairment
A
3rd party
2
Q
What are the 2 commonest causes of impaired cognition
A
Delirium
Dementia
3
Q
Is delirium acute or chronic onset
A
Acute
4
Q
Types of delirium
A
Hypoactive
Hyperactive
Mixed
5
Q
Which type of delirium can be more difficult to spot
A
Hypoactive
6
Q
Key features of delirium
A
Acute onset and fluctuant Disturbance of sleep wake cycle Disturbed psychomotor behaviour Emotional disturbances Delusions (psychotic symptoms)
7
Q
Who is most likely to get delirium
A
Affects extremes of ages Very young Very old Frail People with cognitive frailty (Parkinson's MS, Dementia)
8
Q
What is the commonest complication of hospitalisation
A
Delirium
9
Q
What morbidity and mortality is associated with delirium
A
Increased risk death
Longer length hospital stay
Increased rates institutionalisation
Persistent functional decline
10
Q
Potential precipitates of delirium
A
Infection Dehydration Biochemical disturbance (Na+ and Ca) Pain Drugs Constipation Urinary Retention Hypoxia Alcohol/drug withdrawal Sleep disturbance Idiopathic
11
Q
What is the pathophysiology of delirium
A
Unknown
No one really knows why it happens
12
Q
What is the delirium screening tool
A
4AT
13
Q
Who receives the 4At
A
Everyone >65yrs who is admitted to hospital
14
Q
What can be used to assess the causes/triggers for dementia
A
Time bundle
15
Q
Management for delirium
A
Non-pharmacological
Re-orientate and reassure agitated patients
Use families and carers
Correction of sensory impairment
Normalise sleep wake cycle
Ensure continuity of care (avoid frequent ward or room transfers)
Avoid urinary catheterisation/venflons
16
Q
Pharmacological management of delirium
A
Treat cause (use Time bundle to identify)
Stop bad/precipitating drugs
Stop sedatives
Stop anticholingercis
Drug treatment of delirium not usually necessary
17
Q
What is dementia
A
Acquired decline in memory and other cognitive functions in an alert person
18
Q
Types of dementia
A
Alzheimers Vascular dementia Mixed alzheimer's/Vascular Dementia with Lewy Body Reversible causes (e.g NPH)
19
Q
What is the commonest cause of dementia
A
Alzheimer’s
20
Q
Features of Alzheimer’s
A
Slow insidious onset
Gradually progressive
Loss of memory
Progressive functional decline
21
Q
Risk factors for dementia
A
Increased age
Vascular risk factors
Genetics
22
Q
What type of progression occurs in vascular dementia
A
Step wise
23
Q
What causes vascular dementia
A
Vascular damage in the brain
E.g mini strokes
24
Q
Risk factors for vascular dementia
A
Often have vascular risk factors e.g: Type II DM AF IHD PVD
25
Which disease is linked to dementia with lewy body
Parkinson's
26
Key features of Lewy body dementia
Often very fluctuant
Hallucinations common
Falls common
27
Features of frontotemporal dementia
```
Early behavioural changes (aggression)
Language difficulties
Memory early on often not affected
Lack of insight into difficulties
Will do very strange things (e.g pee on the floor)
```
28
History tools for dementia
MMSE
MOCA
Collateral history
29
Non-pharmacological Rx of dementia
```
Support for person and carers
Cognitive stimulation
exercise
Environmental design
Avoid changes in environment/social support
Advanced care plannig
```
30
Pharmacological Rx Alzheimers
Choliniterase inhibitors (Donepezil)
| Glutamate Receptor Antagonist
Memantine
31
Should anti-psychotics be used in dementia
Avoid if possible
32
Reversible causes od dementia
```
Hypo/hyperthyroidism
Intracerebral bleeds/tumours
B12 deficiency
Hypercalcaemia
Normal pressure hydrocephalus
Depression
```
33
What is capacity specific to
Decision specific
34
What is a welfare POA
Somebody appointed by the person
35
What is a guardian
Somebody appointed by the court
36
```
89yr M
Normally lives independently
“off legs, confused”
reduced mobility
Febrile, “smells of urine”, looks dry
```
```
Normally independent
Still travelling the world
No memory problems
Falls and subsequent sore knee recently
GP started a new tablet
```
What is the most likely diagnosis?
Delirium
37
T or F
92yr lady
PMH diverticular disease
Admitted with vomiting and abdominal pain
Diagnosed with diverticulitis
Treated with IV fluids, IV abx
Agitated and aggressive overnight and very unsteady on feet
• What are we going to do to help Betty?
1. Keep her in bed to reduce risk of fall and fracture
False
| We want to keep her mobile keeping her up and about
38
T or F
92yr lady
PMH diverticular disease
Admitted with vomiting and abdominal pain
Diagnosed with diverticulitis
Treated with IV fluids, IV abx
Agitated and aggressive overnight and very unsteady on feet
• What are we going to do to help Betty?
Insert catheter so not needing to get up to toilet
False
| Only catheterise if real reason to do so
39
T or F
92yr lady
PMH diverticular disease
Admitted with vomiting and abdominal pain
Diagnosed with diverticulitis
Treated with IV fluids, IV abx
Agitated and aggressive overnight and very unsteady on feet
• What are we going to do to help Betty?
Early mobilisation?
True
Get her up and about
allow her to explore her environment
40
T or F
92yr lady
PMH diverticular disease
Admitted with vomiting and abdominal pain
Diagnosed with diverticulitis
Treated with IV fluids, IV abx
Agitated and aggressive overnight and very unsteady on feet
• What are we going to do to help Betty?
Phone her son?
True
| Familiarise her
41
```
82yr old man
Brought to A&E as found walking down street with his pyjamas on
D/w family
Increasingly forgetful over last year
Burns pans
Frequent phone calls to daughter
Accusing carers of stealing
Gradual decline over last 2 years
No significant PMH
Bloods - normal
```
• What is the most likely Dx?
Alzheimers
42
Which of the following drugs is most likely to exacerbate Dementia with Lewy body?
```
o Codydramol,
o Thyroxine,
o Tamsulosin,
o Omeprazole,
o Metoclopramide,
o Ramipril,
o Amlodipine
```
Metoclopramide
| Its a dopamine antagonist
43
2 peaks of urinary incontinence
Old age
| Middle age 3x more common Females
44
Who is urinary incontinence common in
Women
Residential care
Nursing home care
Hospital care
45
Types of incontinence
Stress
Urge
Overflow
Mixed
46
What are the 2 sphincters of the bladder
Internal urethral sphincter
| External urethral sphincter
47
Where do the ureters enter the bladder
Vesico-ureteric junction
48
What is the main muscles of the bladder
Detrusor muscle
49
Is the external urethral sphincter voluntary or involuntary
Involuntary
50
Parasympathetic innervation of the bladder
S2-S4
Secretomotor to the bladder
Detrusor contraction
51
Sympathetic innervation of the bladder
T10-L2 (detrusor muscle relaxation)
| T10-S2 internal sphincter contraction and neck of bladder contraction
52
Describe stress incontinence
```
Urine typically leaks with increased abdominal pressures e.g:
Coughing
Sneezing
Laughing
Standng up
```
53
Causes of stress incontinence
Weak externa sphincter
| Weak pelvic floor muscles
54
What is a major cause of weak pelvic floor muscles
Childbirth
55
Is stress incontinence more common in F or M
Females
56
Non-surgical Rx for stress incontinent
Pelvic floor exercises
(Kegel Exercises)
Oestrogen cream
Duloxetine (SSRI)
57
Aids for pelvic floor muscles
Biofeedback
Vaginal cones
Electrical stimulation
58
Surgical Rx for pelvic floor muscles
TVT
| Colposuspension
59
Describe urge incontinence
Incontinence associated with sudden urge to pass urine
| Overactive bladder
60
Symptoms of urge incontinence
Frequency
Sudden urge
Nocturnal incontinence
61
What is the most common cause of urge incontinence
UMN lesion s
Or
Detrusor muscle disorder
62
Non-pharmacological Rx for urge incontinence
Bladder retraining programme
63
Medication Rx for urge incontinence
Anti-cholinergics (e.g oxybutynin)
Beta-3-adrenorecepotr agonist (Merabegron)
Botulinum toxin
Sacral nerve stimulation
64
Describe overflow incontinence
Urine is retained in the bladder with subsequent overflow
65
Most common cause of overflow incontinence
Often due to bladder outlet obstruction
| More common in older males due to BPH
66
Symptoms of overflor incontinence
Hesitancy
Reduced stream
Post-micturition dribble
67
Rx for overflow incontinence
```
Prostate:
Finasteride (5 alpha reductase inhibitor)
Alpha blocker (Tamsuosin)
Catheter (often suprapubic)
TURP
```
68
General Ix for incontinence
```
Bladder diaries
Examination (abdo./PV/PR)
Urinanalysis/MSSU
Bladder scan
Urodynamics
```
69
2 types of urodynamic studies
Cystometry
| Uroflowmetry
70
General Rx for incontinence
Weight control
Fluid control (reduce caffeine and fruit juice)
Pelvic floor exercises
Bladder retraining
71
What is a neuropathic bladder
Underactive bladder
72
What can neuropathic bladder be secondary to?
Prolonged catheterisation
73
Causes of neuropathic bladder
Rare
Secondary to neurological disease
Typically seen MS or stroke
74
Rx for neuropathic bladder
Catheterisation (even though prolonged catheter may have been the original cause)
75
Criteria for catheter use
Sympathetic urinary retention
Bladder outflow tract obstruction
Undue stress caused by alternative management in elderly/frail/dying
76
Is age or frailty more important in geriatrics
Frailty
77
Why is geriatrics important
Continuing increase in life expectancy
Decrease in total fertility rates
Older people are living for longer
78
Why are people getting older
Increased resources available
Better economic conditions
Improved screening programmes with earlier Dx and Rx
Better outcomes following major events (e.g stroke)
79
What are some theories of ageing
Stochastic (cumulative damage)
Programmed (predetermined, changes in gene expression during various stages)
Homeostasis failure
80
How does ageing affect the kidney
Decrease in kidney function
Creatinine though stays the same due to decreased muscle mass
But creatinine clearance declines with age
81
How does age affect the CVS
Increase BP
Less reserve for diastolic BP
Decreased CO
82
How does ageing affect resp. system
Decreased vital capacity
83
What is dyshomesotatis
When impaired function of any organ system makes it more difficult for the body to maintain a steady state
Essentially fraility is a progressive dyshomeostasis
84
What is social dyshomeostasis
Difficult causes by environmental insults not only bio-medical
Different ability to compensate for social events (e.g death, going on holiday)
85
Do medical conditions in the elderly always present in the same as in adults
No
| Conditions might have different presenting signs and symptoms in people with frailty
86
How does hypothyroidism typically present
Weight loss
Anxiety
Tremor
Diarrhoea
87
How does hypothyroidism present in an older person
```
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Anginga
```
88
What is the evidence gap
Although many conditions are more common in older people
| Few trials of medications are carried out in older people
89
What is the main focus of geriatrics
Frailty
90
What does dyhomeostasis lead to increased risk of
Frailty
91
What is frailty
A susceptibility state
| Increased risk of death or debility following exposure to an environmental stressor
92
Describe the frailty phenotype
Used to spot frailty
3 of 5 criteria
1. Unintentional weight loss
2. Exhaustion
3. Weak grip strength
4. Slow walking speed
5. Low physical activity
93
Name some frailty syndromes
Falls
Immobility
Delirium
Functional loss
94
What is meant by a person centred/goal centred approach
Do hat the patient wants
| Preserve autonomy
95
Which domains of health can people be fail in
```
Medical
Psychological
Functional
Behavioural
Nutritional
Spiritual
Environmental
Social
Societal
```
96
How can psychological domain be affected in elderly
Mood (low mood anxiety)
Confidence (fear of falling)
Cognition (delirium, dementia)
97
How can functional domain be affected in the elderly
Mobility
Activities of daily life
Community living skills
98
Which tool must be used for assessing nutrition
MUST screening tool
99
How can social domain be affected in elderly
Support networks:
Practical/emotional
Formal/Informal
```
Potential for abuse:
Financial
Physical
Sexual
Neglect
```
100
Key professions involved in geriatrics
Geriatrician
OT
PT
Skilled nurses
101
Other professions involved in geriatrics
```
GP
Other doctors
Social worker
Home care
Dietician
SALT
```
102
Aims of Good Geriatric Care (GCA)
Early identification of need
Early comprehensive geriatric assessment
Early provisions of appropriate level or care needs
