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Flashcards in geriatrics Deck (158):
1

describe the 4AT Test

Alert -
AMT4- name, DOB, place, year
Attention - months backwards from december
Acute changes

2

what are consequences of decreased hepatic metabolism of drugs in the elderly

Toxicity
Reduced first pass metabolism
(↑ in bioavailability with some drugs e.g. propranolol
Can cause ↓ bioavailability of pro-drugs e.g. enalapril)

3

which sex is Urinary retention with overflow incontinence more common in

males

4

list some drugs that can increase your chances of falling

TCA antidepressants
antipsychotics
anticholinergics/ antimuscarinis
benzodiazepines
anti-hypertensives
diuretics
alcohol

5

what pathology arises when the bladder outlet is too weak

stress incontinence

6

list some causes of syncope

neurally mediated - vasovagal/ carotid sinus hypersensitivity, situational
postural hypotension
carotid arrhythmias
seizure
structural heart disease

7

what are causes of incontinence that are extrinsic to the urinary system

Physical state and co-morbidities Reduced mobility
Confusion (delirium/ dementia) Drinking too much or at the wrong time
Diuretics Constipation
Home/ social circumstances

8

what diseases common in the elderly decrease total serum a albumin

heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis and some malignancies.

9

what are some causes of incontinence that are necessary to refer from the onset

Vesico-vaginal fistula
Palpable bladder after micturition or confirmed large residual volume of urine after micturitionDisease of the CNS
Certain gynaecological conditions (e.g. fibroids, procidentia, rectocele, cystocele)
Severe benign prostatic hypertrophy or prostatic carcinoma
Patients who have had previous surgery for continence problems

10

who is involved in a comprehensive geriatric assessment

Geriatrician Occupational therapy
Physiotherapist Skilled Nurses
GP
Other doctors
Social worker
Home care
Dietician

11

what is a positive romberg test

sway when eyes are closed

12

what in involved in the societal health domain

attitude - asset or burden
technology
politics - money
accessibility - bus pass, disabled

13

list some cardiac or cardiopulmonary diseases that may lead to syncope

Cardiac valvular disease i.e. aortic stenosis
Acute myocardial infarction/ischaemia
Obstructive cardiomyopathy
Atrial myxoma
Acute aortic dissection
Pericardial disease/tamponade
Pulmonary embolus/pulmonary hypertension

14

what are ECG abnormalities after syncope

inappropriate bradycardia
long QT >450ms
abnormal t wave inversion

15

what are characteristic features of urge incontinence

Detrusor contracts at low volumes
Sudden urge to pass urine immediately
Patients often know every public toilet/ never leave house due to fear – isolating

16

how would you investigate an unexplained seizure in an under 60

holter monitor

17

when is urine leaked during stress incontinence

movement, coughing, laughing, squatting

18

what things can precipitate delirium

Infection (but not always a UTI!) Dehydration
Biochemical disturbance (high low Na/Ca)
Pain
Drugs – opiates (indirect - NSAID/ ACEi > AKI)
Constipation/Urinary retention
Hypoxia Alcohol/drug withdrawal
Sleep disturbance Brain injury -Stroke/tumour/bleed etc
Changes in environment – new social set up

19

why is it more difficult to prescribe for the elderly

little evidence of drug efficacy and safety
multiple medications
adverse drug reactions

20

what symptoms may indicate a seizure over syncope

A bitten tongue
Head-turning to 1 side during episode
No memory of abnormal behaviour that was witnessed before, during or after episode by someone else
Unusual posturing
Prolonged, simultaneous limb-jerking
Confusion after the event
Prodromal déjà vu or jamais vu (recognisable but unfamiliar)

21

how would you investigate syncope

history/ collateral history
examination
12 lead ECG
BP
echo/ halter monitor

22

what are some non pharmacological ways of managing dementia

Support for person and carers Cognitive stimulation
Exercise - fitenss slows down cognitive decline Environmental design
Avoiding changes in environment/social support
Advanced care planning – progressive decline, will lose capacity

23

what happens to rate of absorption of drugs in the elderly

declines

24

what are some prescribing guides for the elderly

BNF
Beer's criteria
STOPP START criteria
NHS scotland polypharmacy

25

how common is delirium in in-pateitns

20-30%
(Up to 50% of all post surgery, Up to 85% in last few weeks of life)

26

who is incontince common in

3x more in woman
2 peaks at 50-59 and 80+
high in hospitalised/ nursing home

27

what does 'start low, go slow' mean when prescribing

start at lowest dose and titrate up slowly

28

how long must dementia symptoms be present for before daignsosis

6 months

29

what are psychological and social complications of immobility

Depression, Loss of confidence
Isolation Institutionalization

30

when is delirium normally worse

night time

31

what test is used to assess bone mass density

DEXA scanning
(T score

32

what type of memory is lost in vascular dementia

executive function eg planning rather than memory

33

what are the most co-morbidities in the 74-102 age group

hypertension
previous solid tumour
angina/ artery disease
respiratory disease
diabetes

34

can you make the diagnosis of osteoporosis without a DEXA scan

if patient has multiple fractures

35

what are screening tools for dementia

MOCA
MMSE

36

what is the treatment for Urinary retention with overflow incontinence

alpha blocker (relaxes sphincter, e.g. tamsulosin) or anti-androgen (shrinks prostate, e.g. finasteride) or surgery (TURP)
may need suprapubic catheterisation

37

how does the body composition change in the elderly that affects the way we metabolise drugs

Reduced muscle mass
Increased adipose tissue (increase distribution of fat soluble drugs)
Reduced body water (decreased distribution of water soluble drugs)

38

give examples of situational syncope

acute haemorrhage · cough, sneeze
· micturition (post-micturition) · post-exercise
- gastrointestinal stimulation (swallow, defaecation, visceral pain)
· others (e.g., brass instrument playing, weightlifting)

39

what are the 6 neurocognitive domains in the DSM 5

complex attention
perceptual- motor function
language function
executive function
learning/ memory
social cognition

40

what percentage of people that fall will fall agin in the next year

66%

41

what are a drugs volume of distribution dependent on

bodys aqueous and lipid phases

42

what sit he stochastic theory of ageing

cumulative damage (micro-trauma), random, gradual degeneration, breakdown of systems e.g. oxidative damage to hair follicles makes hair grey

43

what are treatments for stress incontinence

physiological- kegel exercises
oestrogen cream (atrophy)
duloxetine (SSRI)
TVT
culposuspenison -

44

list some causes of cardiac arrhythmia

Sinus node dysfunction (including bradycardia/ tachycardia syndrome)
Atrioventricular conduction system disease
Paroxysmal supraventricular and ventricular tachycardias
Inherited syndromes (e.g., long QT syndrome, Brugada syndrome)
Implanted device (pacemaker, ICD) malfunction
Drug-induced proarrhythmias

45

which drugs can be given to relax the detrouser

antimuscarinics - oxybutinin, tolterodine, solifenacin, trospium

Beta-3 adrenoceptor agonists - mirabegron

bata 3 adrenoreceptors

46

why does alcohol increase chance of falling

diuretic
reduces cerebellar function

47

why do many drugs lead to confusion in the elderly

increased permeability across the blood brain barrier

48

what 2 things is continence dependent on

effective function of bladder
integrity of neural connections

49

what is the point of a comprehensive geriatric assessment

determine medical problems and health domains
determine what we can reverse and make better
produce a goal centred management plan

50

what is the most common cause of fainting

vasovagal syncope - overstimulation of vagus nerve with sweating, nausea and tunnel vision

51

what drugs produce a lot of adverse effects in the elderly

anticholonergics
sedative

52

what manoeuvre treats benign paroxysmal positional vertigo

dix- hall pike manoeuvre - see nystagmus after head
drop for 20s-1 min, do left and right (asymptomatic side first)

53

list some intrinsic causes that can precipitate a fall

gait and balance - postural instability, vertigo
syncope - cardiac, vagal
chronic disease - parkinson's, peripheral neuropathy, osteoarthritis
visual problems
cognitive disorder
urge incontinence
vit D deficiency

54

what abuse are older people at higher risk for (social domain)

financial
physical
sexual
neglect

55

what neuroinnervation causes contraction of pelvic floor muscle (urogenital diaphragm) and external urethral sphincter.

somatic - S2-4

56

what % of falls result in hip fracture

1% - 1/4 will die as a result

57

why should you do a postural BP after syncope

postural hypotension common cause

58

what is poly pharmacy

use of many drugs

59

what is causing the demographic shift in age of population

fertility rates falling
better healthcare = higher life expectancy
more people surviving surgery, major events, disabilities

60

what are some reversible causes of confusion

Hypothyroidism Intracebral bleeds/ tumours
B12 deficiency Hypercalcaemia
Non pressure hydrocephalus (/cebral atrophy)
depression - irritable

61

which type of dementia has an early onset

fronto-temporal
can be as young as 30

62

what is dyshomeostasis

homeostasis failure
impaired function of organ systems makes difficult
(frailty)

63

what is the cost common form of incontinence

stress incontinence

64

what are reasons for de-prescribing drugs

Adverse drug reaction - Drug-drug interaction - Drug-disease interaction
Better alternative - Not effective
Not indicated
Not evidence-based - Minimise polypharmacy

65

why is stress incontinence common in women after menopause

lose protective effect of oestrogen and muscle begins to atrophy

66

what drugs can be given to relax bladder sphincters

alpha blockers - tamsulosin, terazosin, indoramin

67

what drugs should be stopped in delirium

anticholinergics, sedatives
indirectly harm brain - NSAIDs, ACEi

68

what is important to think about when assessing someones spiritual health domain

whats important to them
whats the meaning of life
how you fit in
how they protect self image

69

how does the effect of protein binding effect drug distribution

Decreased albumin, ↓ binding, ↑ serum levels acidic drugs e.g. furosemide (some drugs only active when unbound)

70

what are common outcomes of a fall

injury (50%) - fracture, subdural haemorrhage
rhabdomyolysis (high CK)
fear of falling
- dependency, carer stress, institutionalisation

71

list was to assess gait and balance

Sitting to standing ability (physio test) -
Static standing balance (control sway)
Gait (weak on one side) Tinetti gait and balance scale
Berg balance scale get up and go test (timed)
Romberg test - proprioceptive function

72

how are creatine levels affected with ageing

although kidney function drops and creatine clearance reduces, levels stay the same due to muscle loss

73

what is the optimal discharge time

when goals are met and before risks outweigh benefits

74

what neuroinnervation increases strength and frequency of bladder contractions

parasympathetic S2-4

75

what are some causes of urge incontinence

bladder stone (dehydration)
stroke

76

what things are vital for balance

vision
hearing (vestibular)
proprioception
cerebellum

77

what negative outcomes are associated with delirium

¥ Increased risk of death
¥ Longer length of stay
¥ Increased rates institutionalisation
¥ Persistent functional decline

78

what causes reduced excretion of drugs by the kidneys in the elderly

renal function decreases with age

79

why do you become incontinent when you fit

lose sympathetic inhibitory tone that stops the bladder from contracting

80

what CNS connections mediated sphincter closure

reflex increase in a-adrenergic and somatic activity

81

why are older people more prone to hypothermia

reduced peripheral vasoconstriction
reduced metabolic heat production

82

what neuroinnervation causes detrouser to relax

sympathetic B-adrenoreceptor
T10-L2

83

what type of muscles are the internal/ external urethral sphincter and detrouser

detrouser + internat - smooth
external - striated

84

what is the ADME of pharmacology

absorption
distribution
metabolism
excretion

85

list healthcare provider factors that contribute to polypharmacy

No med review with patient on regular basis
Prescribes without sufficiently investigating clinical situation – short GP appointments
unclear, complex or incomplete instructions about how to take meds – less adherence
No effort to simplify medication regimen – re-prescribing without thought
Ordering automatic refills
Lack of knowledge of geriatric clinical pharmacology

86

how should you investigate incontinecne

history - extrinsic factors
fluid intake and output diary
examination - rectal and vaginal (atrophy, leakage)
urinalysis and MSSU
bladder scan for residual volume (>500/ 600 abnormal)

87

what pathology arises form an underachieve bladder

neuropathic bladder

88

what screening tool is used for delirium

4AT

89

where is a suprapubic catheter inserted

1cm above pubic symphis

90

why are older people more prone to heat stroke

reduced sweat gland output
reduced skin blood flow
smaller increase in cardiac output
less redistribution of blood flow from renal and splanchnic circulations

91

why is the half life of many drugs increased in the elderly

reduced excretion form kidney

92

why is assessing cognition important

relevant to current medical problems
Associated with increased risk death/increased length of stay/discharge to care home
May need to alter communication/information given/involvement of family members
Help you decide regarding capacity
May alter appropriateness of tests/investigations/certain treatments
May be able to improve it if cognitive impairment – reversible causes

93

what is involved in the non-paharmacological management of dementia

Re-orientate and reassure agitated patients – reitnroduce, USE FAMILIES/CARERS
Encourage early mobility and self-care – improves delerium symptoms
Correction of sensory impairment
Normalise sleep-wake cycle – natural light, owen clothes during day, keep active
Ensure continuity of care - avoid frequent ward or room transfers
Avoid urinary catheterisation/venflons- urinary incontinence/ retention not good enough reason

94

what drugs may be given if the delirious person is at harm to themselves or others

benzodiazepam
quetiapine (anti-psychotic)

95

what is the screening tool for undernutrition

MUST

96

what are risk factors for vascular dementia

vascular risk factors - T2DM, AF, IHD, PVD

97

list some extrinsic causes that can precipitate a fall

inappropriate footwear
environmental hazards - uneven paving, carpet, stairs
poor lighting
unfamiliar environment (hospital)

98

what are physical complications of immobility

Muscle wasting (over 80 10 days = 10 year) Muscle contractures
Pressure sores Deep venous thrombosis
Constipation/ incontinence hypothermia (may lead to pneumonia)
Hypostatic pneumonia Osteoporosis (lack of weight-bearing)

99

what are early symptoms of fronts-temporal dementia

behavioural change
language difficulties
less memory effects early on

100

what happens to the sensitivity of baroreceptors with age

reduce

101

what 5 things would make someone benefit form a comprehensive geriatric assessment (FRAIL)

F - functional impairment with multiple conditions
R - resident in care home
A - acute confusion
I- immobility/ falls in last 3 months
L - list of 6 or more medicines (poly pharmacy)

102

what are the benefits of being in hospital for the elderly

Access to clinical expertise
Access to complex tests and interventions
Rapid access to supervised care support

103

what are some side effects of anti-muscarinics

blurred vision
constipation
dry mouth
reduced cognitions
vasodilation - falls

104

how is the progression of vascular dementia

step wise

105

how frequent are fall related deaths in the UK

every 5 hours

106

what is frailty

A reduced ability to withstand illness without loss of function susceptible state, not an illness in its self

107

what are detrimental affects of physiological aging

systolic hypertension
decreased reaction time

108

what is the only effective treatment for a neuropathic bladder

catheterisation

109

what things can cause orthostatic hypotension

primary autonomic failure
secondary autonomic failure p diabetic neuropathy
volume depletion - haemorrhage, diarrhoea, addison's

110

what things is a neuropathic bladder secondary to

near disease - MS, stroke
prolonged catheterisation

111

at how many drugs are you guaranteed an ADR

9 - most elderly on

112

what is the programmed theory of ageing

pre-determined, changes in gene expression during various stages (cell death – apoptosis)

113

what tools is used to assess risk of osteoporosis

QFRACTURE, FRAX

114

what is the name of the micturition centre in the brain

pontine micturition centre

115

what are risk factors for frailty (DECLINE)

D – diabetes/ insulin resistance
E- elderly
C – chronic disease
L – lack of use (of muscle)
I – inflammation
N - nutritional deficiency
E – endocrine dysfunction

116

what is frailty scored on

1 - very fit
2- well
3 - managing well
4 - vulnerable
5 - mildly frail
6- moderatley frail
7- severely frail
8- very severely frail
9 - terminally ill

117

what would you want to find in the history of cognitive impairment

onset - when , how rapid
course - fluctuating, progressive decline
associated - illnesses, functional loss

118

what is social dyshomeostasis

difficulty caused by environmental insults e.g different ability to compensate for situations such as death, social isolation

119

what does voluntary voiding of the bladder involve

voluntary relaxation of external sphincter and involuntary relaxation of internal sphincter and contraction of bladder. (parasympathetic drive)

120

what are the 5 domains of the frailty phenotype

unintentional weight loss
exhaustion
weak grip strength
slow walking speed
low physical activity

121

list things that can cause vertigo

menieres
labrynthitis
benign paroxysmal positional vertigo
acute ear infection
cerebellar/ brainstem pathology

122

what is a safer way of treating urinary incontinence than long term catheterisation

intermittent catheterisation - 4x a day

123

what symptoms would indicate a syncope over a seizure

Prodromal symptoms that on other occasions have been abolished by sitting or lying down
Sweating before the episode
Precipitated by prolonged standing
Pallor during the episode.

124

what condition often co-exist with leeway body dementia

parkinsons

125

list symptoms of ADRs in the elderly

Unsteadiness/ falls -
Dizziness/ drowsiness
Confusion
Nervousness
Fatigue
Insomnia
Depression
Incontinence

126

what are some pharmacological ways of managing dementia

Cholinesterase inhibitors - Mainly used in Alzheimers,
Galantamine licensed in mixed dementia
Rivastigmine in Dementia with Lewy Bodies

127

what is fear of falling syndrome

loss of confidence in ability to walk - develop distinctive gat that actually increases your chances of falling

128

what drug actually has a higher absorption in the elderly

levodopa (parkinsons) -

129

what are the worst drugs for poly pharmacy

1.NSAIDs
2. Diuretics
3. Warfarin
4. ACEI
5. Antidepressants
6. Beta blockers
7. opiates
8. Digoxin
9. Prednosiolone/ clopidogrel

130

what are common symptoms of lewy body dementia

hallucinations (nightmares)
falls
very fluctuant

131

what is regarded as failure of initial management for urinary incontinence (refer)

3 month of pelvic floor , cone therapy, medication

132

what is subclavian steal syndrome (syncope)

blockage in subclavian artery, blood down verterbal artery to rigt arm instead of brain

133

what is involved in the psychological health domain

mood - low, anxiety
confidence - fear of falling
cognition - dementia, delirium

134

at what bladder volume do you become aware that you are full

250ml

135

what pathology arises when the bladder outlet is too strong

urinary retention with overflow incontinence

136

why does a neuopathic bladder lead to overflow incontinence

no awareness of bladder filling

137

what is a fall

Inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force

138

what pathology arises from the bladder muscle being too strong

urge incontinence

139

what 4 things contribute to good geriatric care

Early identification of need
Early Comprehensive Geriatric Assessment
Early provision of appropriate level of care for needs
Discharge plan or dignified death

140

what are the 9 health domains of a comprehensive geriatric assessment

medical
psychological
functional - mobility/ living
behavioural
nutritional
spiritual
environmental
social
societal

141

what are the key features of delirium

Disturbed consciousness – Hypoactive (sleepy)/hyperactive (up exploring)/mixed
Change in cognition - Memory/perceptual/language/illusions/hallucinations
Acute onset (few hours) and fluctuant
Affects extremes of age - smaller insults

142

what are red flags for syncope

An ECG abnormality
Heart failure (history or physical signs)
Onset with exertion
Family history of sudden cardiac death (<40) years and/or an inherited cardiac condition
New or unexplained breathlessness
A heart murmur.

143

how is urge incontinenc treated

anti-muscarinics (relax detrusor) e.g. oxybutinin, tolterodine, solifenacin

144

why is hepatic metabolism of drugs affected in the elderly

decreased liver mass
decreased liver blood flow

145

what neuroinnervation causes contractions of neck of bladder and internal urethral sphincter

sympathetic a-adrenoreceptor (T10-L2)

146

what are risk factors for a fall

muscle weakness
history of falls
gait/ balance deficit
use of assistive devices
visual deficit
arthritis
cognitive impairment
age >80

147

what lung volume changes with ageing

vital capacity

148

why does the loading dose of digoxin have to be substantially lowered in the elderly

normally high Vd due to widespread distrubution into the muscle
The reduction in muscle mass in older people means there is a significant reduction digoxins Vd

149

what is th eMDT treatment of falls

treat cause where possible
Strength and Balance Training
Home Hazard and Safety Intervention – fall alarms, fall monitors
Medication review with modification/withdrawal
Cardiac pacing - In selected patients found to have cardio-inhibitory carotid sinus hypersensitivity and unexplained falls

150

what symptoms would indicate a syncope over a seizure

Prodromal symptoms that on other occasions have been abolished by sitting or lying down
Sweating before the episode
Precipitated by prolonged standing
Pallor during the episode.

151

what are causes of incontinence that are intrinsic to the urinary system

bladder outlet too weak or strong
urinary outlet too weak or strong

152

what are common causes of Urinary retention with overflow incontinence

blockage of urethra
men - BPH
women - cervical cancer survivor, urethral stricture from radiotherapy

153

what is involved int eh behavioural health domain

occupation
pastimes
habits - smoking, drinking unhealthy eating

154

what should you do regularly for an elderly patient on many drugs

review regularly
remove any unnecessary drugs

155

what are things you would want to gather from the collateral history after a syncope

Circumstances of the event
Posture immediately before loss of consciousness (sitting/ standing/ lying)
Appearance (pale,/ cold/ clammy)
Presence or absence of movement during the event (?limb-jerking)
Tongue-biting
Duration of the event (onset to regaining consciousness),
Presence or absence of confusion during the recovery period
Weakness down 1 side during the recovery period.

156

what are risks of being in hospital for the elderly

Disorientation and delirium
Learned dependency Deconditioning – lose muscle strength
Iatrogenic harm – drug side effects
Hospital Acquired Infection

157

what are characteristic features of Urinary retention with overflow incontinence

poor urine flow
double voiding
hesitancy
post micturition dribbling

158

what type of memory do you lose first in alzheimers

recent memory - functional decline in daily activities