Geriatrics Flashcards
(34 cards)
Population increasing
- Increased resources
- Better economics
- Better screening
- Better outcomes following illness e.g. MI
Ageing
- Progressive accumulation of damage to a complex system resulting in loss of system redundancy
- Decreased resilience to overcome environmental stress (frailty)
- Leads to increased risk of system failure: organ function decline -> dyshomeostasis
Frailty
A susceptibility state that leads to a person being more likely to lose function in the face of a given environmental challenge (dyshomeostasis)
- State of susceptibility to environmental stress
Frailty investigation
Medical conditions tend to present as functional decline (frailty syndromes): falls, delirium, immobility, incontinence.
Frailty index (>0.12)
Fried criteria (3/5) - phenotype:
- Unintentional weight loss
- Exhaustion
- Weak grip strength
- Slow walking speed
- Low physical activity
Clinical frailty scale (spectrum)
Multimorbidity
Presence of 2 or more long-term health conditions
Causes of ill health in older people
Complex mix of factors:
- Medical
- Physical/functional
- Psychological
- Spiritual
- Behavioural
- Nutritional (MUST screen tool)
- Environmental
- Social
- Societal
- Sexual
Comprehensive Geriatric Assessment (CGA)
Inter-disciplinary approach to investigation and management important
- Goal centred
- Holistic approach
- MDT
Incontinence
Symptom of lack of voluntary control over urination or defaecation.
Depends on effective function of bladder and integrity of neural connections of voluntary control.
Incontinence causes
- Physical state and co-morbidities
- Reduced mobility
- Confusion
- Abnormal intake
- Medications
- Constipation
- Home/social circumstances
- Bladder/urinary outlet pathology
Incontinence investigations and management
- History and examination
- Intake/output chart
- Urinalysis and MSSU
- Bladder scan (residual volume)
Management
- Lifestyle/behavioural changes
- Modify medications (diuretics)
- Referral: physio, surgery
- Medical options
- Incontinence pads, urosheaths, catheter
Stress incontinence
Bladder outlet too weak (weak pelvic floor muscles + increased abdominal pressure)
- Women with children, after menopause
Management:
- Physiotherapy (pelvic floor exercises)
- Vaginal cones
- Oestrogen scream
- Duloxetine
- Surgery: TVT, colposuspension
Urinary retention with overflow incontinence
Bladder outlet ‘too strong’ (urethral blockage, bladder unable to empty)
- Older men with BPH: poor flow, double voiding, hesitancy, post-micturition dribbling
Management:
- Alpha blocker (relaxes sphincter)
- Antiandrogen
- Surgery e.g. TURP
- Catheterisation
Urge incontinence
Bladder muscle ‘too strong’ (detrusor overactivity - low volume micturition)
- Bladder stones, neurologic disorders, infection
- Sudden urge to pass urine immediately
Management:
- Antimuscarinics (relax detrusor)
- B3 adrenoceptor agonist
- Bladder retraining
Neuropathic bladder
Underactive bladder (results in overflow incontinence) - Neurological disease, prolonged catheterisation
Management:
- Catheterisation
Delirium
Acute, fluctuating change in mental status
- Inattention
- Disorganised thinking
- Altered consciousness
Multifactorial
Delirium predisposing factors
Reduced functional reserve
- Frailty
- Older age
- Dementia
- Previous delirium
- Dehydration
- Polypharmacy
- Co-morbidities
Delirium precipitating insults
Illness
- Neurological injury (stroke, tumour, haemorrhage)
- Infection/fever
- Cardiac
- Constipation, urinary retention
- Pain
Haemodynamics
- Dehydration
- Shock
- Hypoxia
Environmental
- Iatrogenic (surgery, medications)
- Distress
- Social
- Alcohol/drug withdrawal
- Sleep deprivation
Delirium symptoms
- Disturbed consciousness (hypo/hyperactive/mixed)
- Change in cognition
- Disturbed psychomotor behaviour
- Functional decline: falls etc
- Disturbed sleep-wake cycle
Delirium investigations
TIME;
- Think, treat triggers
- Investigate (intervene)
- Management
- Engage, explore, explain (patient and family)
Screen:
- Confusion assessment method (CAM)
- 4AT score
Delirium management
Treat cause
- Issue with capacity
Non-pharmacological
- Reassure
- Encourage early mobility
- Correct sensory impairment
- Normalise sleep-wake cycle
- Avoid catheterisation
Pharmacological
- Change medication
- Anti-psychotics
MDT: CGA
Prevention
Causes of falls
MSK: arthritis, sarcopenia, feet deformities
Medication: anti-hypertensives, b-blockers, sedatives, anticholinergics, opioids, alcohol
Neuro: stroke/TIA, parkinsonism, dementia, delirium, ataxia, seizure
Sensory: visual impairment, inattention
CVS: postural hypotension, HF, arrhythmia, aortic stenosis
Incontinence
Investigation of falls
History: before/during/after fall
- Collateral
Examination Bloods: glucose ECG Delirium screen (4AT, CAM) Imaging: CT head, x-ray
Management of falls
MDT
- Correct medication
- Physiotherapist
- Specialist nurses
Prevention:
- Vision
- Mobility aids, call bell and possessions in reach
- Bed rails
- Height of bed
- Regular obs
CT indications after fall
- GCS<13
- Confusion after 2 hours
- Focal neurology
- Skull fracture signs (bruising around eyes, behind ears)
- Seizure
- Vomiting
- Anticoagulation
