Geriatrics Flashcards
(114 cards)
1
Q
What are the 3 theories of ageing?
A
Stochastic
Programmed
Homeostasis failure
2
Q
What is the stochastic theory of ageing?
A
Cumulative damage in cells with occurring randomly leading to replicative errors
3
Q
What is the programmed theory of ageing?
A
Predetermined changes in gene expression at different points in life
4
Q
Outline some of the etiological theories with regards to ageing
A
- Improved screening outcomes
- increased resource availability
- increased availability of resources and economic availability
- more people survive a major event and have several co-morbidities (better outcomes for surgery, stroke and cardiac disease)
5
Q
What is classed as primary ageing?
A
Arthritis
Reduced GFR
6
Q
What is Classed as secondary ageing?
A
accumulating more time at risk of certain diseases
7
Q
Outline the functional decline in the pathophysiology of ageing
A
% of maximum function declines with age but this varies a lot between individuals and this variability increases with age
- EVIDENCE GAP for >80 yo
most drugs used to treat elderly are not actually trialled in elderly
8
Q
What is the effect of ageing on the renal system?
A
- Decreased creatinine clearance so decreased GFR
- BUT less creatinine to clear as less muscle mass
9
Q
What is the effect of ageing on the CVS system?
A
- Increased systolic BP, decreased diastolic BP
- decreased CO
10
Q
What is the effect of ageing on the respiratory system?
A
- Decreased peak flow and gas exchange
- decreased lung function tests e.g. FVC, TV, VC
- Weakening of resp muscles
- decreased effectiveness of defence mechanisms
11
Q
Outline the definition of frailty
A
- Cycle of decline, crisis, admission and reablement
- A SUSCEPTIBILITY STATE that leads to a person being more likely to lose function in the face of a given environmental challenge
12
Q
3 or more of the these = the frailty phenotype
A
- Unintentional WL
- Exhaustion
- Weak grip strength
- Low physical activity
- Slow walking speed
13
Q
What are the 4 frailty syndromes (system failure presentations)?
A
- Falls
- Immobility
- Functional loss
- Delirium
14
Q
What is the aim of a comprehensive geriatric assessment?
A
Assessment & management of illness in the frail elderly with a PERSON/GOAL CENTRED approach (multi-dimensional)
15
Q
What kind of things are included in a CGA?
A
- preserve autonomy - goal centredness
- deal with multi-morbidities and competing clinical priorities
- determine problems and identify what is reversible or can be improved
- produce management plan
- MDT
- improves outcomes and earlier discharge
16
Q
What are the affected health domains in ageing the?
A
- Medical
- Psychological
- Functional
- Behavioural
- Social
- Environmental
- Nutritional
- Societal
- Spiritual (person centred care)
17
Q
Describe the link between frailty and dyshomeostasis
A
- Frailty = progressive dyshomeostasis
- impaired function of ANY organ makes maintenance of a steady state more difficult
18
Q
What is senescence?
A
Impaired organ function so dyshomeostasis so susceptibility to environmental stress and frailty
19
Q
What medical aspects of health are covered in the CGA?
A
- Reversible or irreversible
- Multi-morbidity
- Iatrogenic harm
- Curable (infection or iatrogenic)
- Physiological (normal ageing) or pathological (disease)
20
Q
What psychological aspects of health are covered in the CGA?
A
- Mood - low mood or anxiety
- Cognition - dementia or delirium
- Confidence - fear of falling syndrome
21
Q
What functional aspects of health are covered in the CGA?
A
- Mobility
- ADLs - transfers, mobility, toileting, washing, dressing, meal prep, feeding
- community living skills
22
Q
What behavioural aspects of health are covered in the CGA?
A
- determinants e.g. smoking
- activities/hobbies
- occupation
23
Q
What social aspects of health are covered in the CGA?
A
- support networks: practical/emotional, formal/informal
- potential for abuse (financial/physical/ sexual/ neglect)
24
Q
What environmental aspects of health are covered in the CGA?
A
- Housing and heating
- Sanitation
- Adaptations
25
What nutritional aspects of health are covered in the CGA?
- MUST screening tool
| - Poor health and poor nutrition lead to one another
26
What societal aspects of health are covered in the CGA?
- Political/regulations
- attitudes
- technological advances
27
What spiritual aspects of health are covered in the CGA?
- Bigger picture, what is important to you
- project self-image
- meaning in life
- what is important to you
28
What are the benefits of being admitted to hospital as an elderly person?
- clinical expertise
- complex tests and interventions
- rapid access to supervised care and support
29
What are the risks of being admitted to hospital as an elderly person?
- Disorientation and delirium
- learned dependency
- deconditioning
- iatrogenic harm
- healthcare associated infection
30
How is absorption affected in older people (pharmacokinetics)?
- reduced RATE of action but NOT extent (delayed onset)
| - Levodopa = exception - quicker to peak plasma level due to less metabolism in saliva
31
How is distribution affected in older people (pharmacokinetics)?
- changes in body composition
- increased adipose tissue - increases Vd, T1/2 and duration for fat soluble drugs
- decreased body water - decreased Vd and increased serum levels for water double drugs
- changes to protein binding - reduced binding and increased serum levels of acidic drugs
- increased serum levels of highly protein bound drugs
32
How is metabolism affected in older people? (pharmacokinetics)
- Reduced liver mass and blood flow - increased toxicity
| - reduced 1st pass metabolism - different bioavailability of certain drugs
33
How is excretion affected in older people (pharmacokinetics)?
Renal function declines so reduced clearance and increased half-life - Increased TOXICITY
34
Outline the changes in pharmacodynamics in the elderly
Increased sensitivity due to
1) changes in receptor binding
2) reduced receptor number
Altered translation of receptor-initiated response to biochemical reaction
35
What is Beer's criteria?
Inappropriate drugs for older people
| but has many weaknesses
36
What prescribing tools are there for prescribing in the elderly?
- Beer's criteria
- Polypharmacy guidance
- START-STOPP criteria
37
What is START-STOPP criteria?
Tool used in prescribing for elderly
Optimisation advice
e.g. stop codeine for diarrhoea as may mask gastroenteritis, start a fibre supplement in diverticular disease
38
Which drugs are a falls risk?
- Tolterodone - anticholinergic
- Bendroflumethiazide - hyponatraemia, hypotension
- Omeprazole - hyponatraemia, osteoporosis
- Sertraline - orthostatic hypotension, hyponatraemia
39
What are the central side effects of anticholinergics?
- Memory impairment
- Confusion
- Agitation
- Disorientation
- Delirium
- Hallucinations
- Falls
40
What are the peripheral side effects of anticholinergics?
- Dry mouth and eyes
- Constipation
- Visual accommodation problems and pupil dilatation
- Urinary retention
- Decreased sweating
- Inhibition of penile erection
41
Outline the problems with psychiatric drugs in the elderly
- care treating agitation
- Benzos have increased effects wrt falls, sedation and confusion
- anti-psychotics can cause postural hypotension, stroke, confusion and movement disorders
- Anti-depressants less effective and more dangerous
- sedatives are problematic
42
Outline the problems with analgesia in the elderly
- Opioids are more sensitive so given in lower doses (but may be less sensitive to tramadol and pethidine)
- NSAIDs - increased SEs of renal impairment and GI upset/bleeding
43
Outline the problems with antibiotics in the elderly
- Increased SE:C diff, diarrhoea
- Co-trimazole causes delirium
- Quinolones cause seizures/delirium
- Aminoglycosides contraindicated due to renal impairment
- Blood dyscrasia (trimethoprim, co-trimox)
44
Outline the problems with cardio drugs in the elderly
- DIGOXIN - increased toxicity
- DIURETICS - reduced peak effect and reduced clearance, cause continence and immobility
- Anti-hypertensives have exaggerated effect on BP and HR
- Anti-coags - more sensitive to Warfarin, great risk from Warfarin - GI bleed, falls
45
How may a frail person present with hyperthyroidism compared to a normal person?
Frail: depression, CI, weakness, A Fib, HF, angina
Not frail: tremor, anxiety, WL, diarrhoea
46
When may deprescribing be useful?
- Some evidence that it is safe to stop antihypertensives, benzodiazepines, antipsychotics
- Stop statins in last year of life
- most ADRs events from anticholinergics and sedatives
47
Outline the pathology of Alzheimers
Amyloid plaques in brain
48
Outline the aetiology of dementia
- Alzheimer's (50%)
- Vascular dementia (25%)
- Mixed Alzheimer and vascular (15%)
- Lewy Body dementia (5%)
- Others ie frontotemporal dementia, brain disorders such as Huntington's and Parkinsons , head injury
49
What are reversible causes of dementia?
- Hypothyroidism
- Intracerebral bleeds/tumours
- B12 deficiency
- Hypercalcaemia
- Normal pressure hydrocephalus
50
What is dementia by definition?
Chronic global cognitive impairment; progressive
51
Describe the ABCD clinical syndrome of dementia
A - Activities of daily living
B - behavioural and psychiatric symptoms of dementia (BPSD)
C - cognitive impairment
D - decline
52
Outline Alzheimer's disease in Dementia
Slow insidious onset
Loss of recent memory first
progressive functional decline
53
Outline Vascular dementia in Dementia
Step wise deterioration
Executive function may predominate
often associated w/ gait problems
54
Outline Lewy Body dementia in Dementia
Deficits of Attention, frontal executive and visuospatial
- amnesia NOT prominent
- 2 = probable, 1 = possible of fluctuation, visual hallucinations, Parkinsonisms
55
What is suggestive of Lewy body dementia? and what is it supported by?
Suggestive - REM sleep disorder, severe antipsychotic sensitivity, abnormal DAT scan
Supported by: falls, syncope, LOC, other psych symptoms, autonomic dysfunction, scans
56
Outline fronto-temporal dementia in Dementia
Tends to have a younger onset
- behavioural disorder (personality change)
- speech disorder
- neuropsychology (frontal dysexecutive syndrome)
- Neuroimaging - abnormalities on temporal lobes
- Neurological signs absent early, later get Parkinsonism, sometimes MND, autonomic, incontinence, primitive reflexes
57
What is the criteria for dementia?
- Present for > 6 months
- Acquired cognitive decline - memory (dysmnesia) + 1 of :
Dysphasia (expressive or receptive)
Dyspraxia
Dysgnosia
Dysexecutive functioning
FUNCTIONAL DECLINE IN ADLs - forgetting to take tablets, unable to use phone, problem's washing/dressing
58
How would you diagnose dementia?
- History and collateral
- Risk assessment
- MMSE/MOCA
- Bloods: FBC, ESR/CRP, U&E, LFTs, Glucose, Ca, TFT, B12, red cell folate
- neuroimaging
59
What are the side effects of cholinesterase inhibitors in the treatment of dementia?
What are the contraindications?
Generally safe but SEs:
- N&V, diarrhoea
- Fatigue, insomnia
- Muscle cramps
- headache
- dizziness
Contraindications:
- bradycardia, syncope, gastric ulcer, respiratory problems
60
Outline how dementia will affect driving?
Notify DVLA at Dx
Should not drive if:
- poor ST memory
- disorientation
- lack of insight
61
Assessing capacity in dementia involves..
Can they:
- act
- make
- communicate
- understand
- retain memory of
Task specific e.g medical treatment, hospitalisation
62
What is the epidemiology of delirium?
- Commonest complication of hospitalisation
- 20-30% of all hospital inpatients
- 50% post-surgery
- 85% of EOL
- Large morbidity & mortality
- Preventable in 30% of cases
63
What precipitates delirium? Aetiology
- infection
- dehydration
- biochemical disturbance
- pain
- drugs
- constipation/urinary retention
- hypoxia
- drug/alcohol withdrawal
- sleep disturbance
- brain injury: stroke/tumour/bleed
- SLE
- cerebral vasculitis
- vitamin deficiencies
- endocrinopathies
- paraneoplastic syndrome
64
Outline the pathophysiology of delirium
- acute organic confusional state
| - maladaptive sickness response involving systemic inflammation
65
Why bother with delirium?
- Massive M&M
- increased risk of death
- longer length of stay
- increased rates of institutionalisation
- persistent functional decline
- acute or subacute onset characterised by global cognitive impairment
66
What are the key features of delirium?
- Disturbed consciousness
- Change in cognition (memory/perceptual/ language/hallucination)
- Acute onset and fluctuant
67
What are other common features of delirium?
- Disturbance of sleep wake cycle
- disturbed psychomotor behaviour (affects your physical function)
- emotional disturbances
- delusion
68
What are the symptoms of delirium?
- Impaired attention/concentration
- Anterograde memory impairment
- disorientation in time, place or person
- fluctuating levels of arousal (often nocturnal exacerbations)
- disordered sleep/wake cycle
- increased/decreased psychomotor activity
- disorganised thinking
- perceptual distortions, leading to misidentification, illusions and hallucinations
- changes in mood such as anxiety, depression and lability
69
What test is used to diagnose delirium?
4AT
4 or > = possible delirium or cognitive impairment
1-3 = possible CI
0 = delirium/cognitive impairment unlikely
70
Should you use a dipstick for the diagnosis of UTI in older people?
NO
| Sign 88 guidelines
71
What is the TIME bundle when assessing/managing delirium?
T - think exclude & treat poss triggers
I - investigate and intervente to correct underlying cause
M - management plan
E - engage and explore; talk to and involve family
72
What things may trigger delirium that you should assess in your full examination and TIME bundle?
- NEWS - sepsis 6
- Blood glucose
- Medication Hx: new medication, dose changes, medication recently stopped
- assess for urinary retention
- assess for constipation
73
How should you investigate and intervene when assessing for delirium?
- assess hydration, start fluid balance chart
- pain review (Abbey pain scale)
- Bloods (FBC, U&E, Ca, LFTs, CRP, Mg, Glucose)
- Symptoms and signs of infection and perform appropriate investigations
- ECG for ACS
74
What is the pharmacological treatment of delirium?
STOP anti-cholinergic & sedatives
Drug tx not usually necessary but if absolutely needed (danger to self and others and cannot be settled in any other way) - QUETIPINE - 12.5mg oral - cons/reg decision
75
What is a non-pharmacological treatment of delirium?
- Re-orientate and reassure
- Use families and carers
Get them in at meal times
- early mobility and self care
- correct sensory impairment
- ensure continuity (avoid room/ward transfers)
- avoid catheters and venflon
76
What is the trajectory and FU for delirium?
- usually settles quickly with management of underlying cause
- increasingly recognise that a lot of people don't get back to previous level
- may unmask previously undiagnosed cognitive impairment
- more likely to go on and develop dementia
- RF for further episodes of delirium/dementia/frailty syndromes
77
Do people with delirium have capacity?
Capacity is decision specific
| Welfare POA or guardian ?
78
Outline the epidemiology of falls
Annually effects 30% of >65
40% of >80
50% in hospital or care homes
- more mortality than sepsis in elderly
79
Aetiological causes of falls are made up of ______, ______, _____ and other factors
Intrinsic
Extrinsic
Situational
80
Name some extrinsic factors of falls
- Inappropriate footwear
- Environmental hazards (uneven paving, carpets, walking aids, stairs)
- Poor lighting
81
Name some situational factors of falls
- Alcohol
- Urgency of micturition
- Medications- change BP, HR, awareness, increase UO, sedation, qTC, dizziness
82
Name some intrinsic factors of falls
- Gait and balance
= postural instability
= cerebral perfusion (reduced CO, reduced vasomotor tone e.g. by GTN
= Vestibular: dizziness due to unsteadiness, vertigo - labyrinthitis, acute OM, BPPV, Menieres disease, cerebellar or brainstem pathology
83
Name some other factors of falls
- syncope (CVS, vagal, other) - think Aortic stenosis
- chronic disease (MSK or neurological)
- Acute illness - limited physiological reserve leading to hypoxia, impaired central processing and correction of imbalance
- cognitive disorder (dementia, delirium, depression)
- Vitamin D deficiency
84
What 2 things need excluding in someone who has had a fall?
Syncope
| Seizure
85
In someone who has had a fall, what should you examine?
- Injuries (hip, wrist, vertebrae # most common)
- chronic disease
- acute illness (LRTI, UTI, dehydration)
- Cognitive dysfunction
- Look at feet (footwear, toenails), check vibration sense, sensation and proprioception
- gait and balance assessment
- syncope assessment
- seizure assessment
86
Suspect a seizure if 1 or more of the following are present:
- bitten tongue
- head turning
- no memory
- unusual posture
- prolonged
- simultaneous limb jerking
- confusion after
- prodromal deja vu or jamais vu
87
When may a seizure be unlikely in a fall?
- If prodromal
- other occasions resolved by lying down
- precipitated by standing
- sweating or pallor during episode
88
As well as a full examination, what else should be investigated in a fall?
- Basic bloods: FBC, U&E, LFT, TFT, B12 and vit D, folate, CK
- Random blood glucose
- 4AT delirium
- consider CT head if fall + head injury and Neuro signs or anticoagulated
- assess fracture risk
89
If you have delirium, you are ___ times more likely to fall
4.5
90
______ prevention interventions also reduces falls
Delirium
91
In the falls clinic where an MDT is present, what kind of things are done?
- Eye test, ECG, L/SBP, incontinence questionnaire, MMSE
- full assessment of gait and balance
- thorough hx and examination, consider bone health and osteoporosis screening
92
If a patient falls on exertion what should you assume is the cause?
Aortic stenosis
93
If a patient falls on turning what should you assume is the cause?
Postural instability
94
Are there any drugs you should specifically ask about when assessing falls?
OTC antihistamines, alcohol
95
Those with a history of falls should be managed how?
- treat underlying cause
- strength and balance training
- home hazard intervention
- medication review with modification and deprescribing
- cardiac pacing: selected patients with cardio-inhibitory carotid sinus sensitivity and unexplained falls
- treat fractures
- treat osteopenia/porosis
96
What should you treat all those with osteopenia/porosis who have fallen?
- Calciumn and vitamin D supplementation
| - Consider IV bisphosphonates, teriparatide or densosumab
97
What may an ataxic gait suggest?
Cerebellar damage
98
What may an arthralgic gait suggest?
arthritis
99
What may a hemiplegic gait suggest?
Stroke
100
What may small steps/shuffling gait suggest?
Parkinsonism
101
What may a high stepping gait suggest?
Peripheral neuropathy
102
When should you perform a CT head after an inpatient fall?
If:
- Low GCS <13
- Still confused after 2 hours (or not back to baseline)
- Focal neurology
- Signs of skull fracture
- Basal skull fracture - CSF leak, bruising around eyes
- Seizure
- vomiting
- anti-coagulation
103
What are the RFs for immobility?
- diabetes or insulin resistant
- elderly
- chronic disease
- lack of use
- inflammation
- nutritional deficiency
104
Outline the pathophysiology with immobility/falls
SARCOPENIA - loss of skeletal muscle mass and strength as a result of ageing
- sarcopenia, elimination problems, lead to loss of confidence, injury and pain
105
What are some of the physical complications of immobility/falls?
- Muscle wasting
- contractures
- pressure sores
- DVT
- constipation/incontinence
- hypothermia
- hypostatic pneumonia
- osteoporosis
106
What are some of the psychological complications of immobility/falls?
- depression
| - loss of confidence
107
What are some of the social complications of immobility/falls?
- Isolation
| - Institutionalisation
108
Anticholinergics cause _____, dry mouth, ______, blurred vision, ______ retention and orthostatic _______
confusion
constipation
urinary retention
orthostatic hypotension
109
Tricyclics cause _____ and _____ gait in the elderly
confusion
| unsteady
110
Digoxin causes ______ with normal serum concentration
toxicity
111
Long acting benzodiazepines cause ____ toxicity in the elderly
CNS
112
Narcotics in the elderly cause ______
confusion
113
ADRs in the elderly look like '_______ ___'
growing old
- unsteadiness
- dizziness
- confusion
- nervousness
- fatigue
- insomnia
- drowsiness
- falls
- depression
- incontinence
114
What is the therapeutic range known to be between?
MTC and MEC
