Geriatrics for long case

Question 1

Geriatric depression score

Answer 1

1. Are you happy with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel like your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home, rather than going out and doing things?
10. Do you feel that you have problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do think most people are better off than you?
    >5 possible depression, >10 likely depression

Question 2

Fried/Hopkins index for frailty

Answer 2

• Unintended weight loss
• Exhaustion
• Muscle weakness
• Slowness while walking
• Low levels of activity
• (at least 3 of these criteria are considered frail)

Question 3

MMSE

Answer 3

• Orientation to time place – country, state, suburb, building, floor
• Remember – ball, flag tree – recite then recall
• Ability to count down from 100 by 7 or spell world backwards
• Repeat – no ifs ands or buts
• Naming – pen shirt glasses
• Follow written command – “close your eyes”
• 3 step command with paper
• Write a sentence
• Copy intersecting pentagons
• Draw clock face, then time

Question 4

Falls risk factors - precipitants

Answer 4

• neurology – PD, leg weakness, sensory deficit, visual impairment, prior stroke; dementia/delirium; myopathy – prednisolone, statin
• Vertigo- BPPV, stroke, menieres
• pain – osteoarthritis, rheumatoid arthritis, osteomalacia, disc prolapse, neuropathy, prior trauma;
• Deconditioning/ weight loss – prior ICU stay/hospital stay
• Dyspnoea – severe heart or lung disease
• Cardiovascular precipitants – arrhythmias – brady/tachy – AF, orthostatic hypotension
• recurrent syncope or postural hypotension – drugs, cough syncope, micturition syncope
• Alcohol consumption, benzodiazepines, antidepressants
• Intercurrent illness -anaemia, sepsis, dehydration

Question 5

Falls - mortality/morbidity

Answer 5

• Injuries associated with fall, ICH
• Associated osteoporosis and fractures, previous joint replacements
• Associated bleeding risk – HASBLED score – liver disease, INR, HTN, renal disease, alcohol, anticoagulant use, age >65, prior severe bleeding, stroke history

Question 6

Falls - exam

Answer 6

Postural BPs, AF
Cachexia
timed up and go
Tone, finger snaps, gait for parkinsons
Finger nose/heel-shin for cerebellar ataxia
Proprioceptive loss
Evidence of hemiplegia
Evidence of joint deformity

Question 7

Falls management

Answer 7

• Use of walking aids, hip protectors
• Weight bearing exercises, hydrotherapy, community physiotherapy
• Visual aids
• Bisphosphonate therapy, calcium vitamin D
• Medication review – cessation of anticoagulants, benzos, SSRIs etc.
• etOH avoidance
• Management of pain – NSAIDs, paracetamol, opioids, breakthrough, physiotherapy, local nerve blocks, pain specialist, ketamine infusions

Question 8

Falls - investigations

Answer 8

• Postural BPs, ECGs, neurology review, tilt table testing, CT scans, X rays hips, pelvis
• Timed up-and-go, physiotherapy assessments, home assessments, aged care assessments, occupational assessments

Question 9

falls -complications

Answer 9

• Subdural haematoma, intracranial haemorrhage
• Fractures
• Anxiety and loss of independence
• Rabdomyolysis, sepsis, AKI

Question 10

Osteoporosis risk factors

Answer 10

• Other bone disorders -renal bone disease, pagets, hyperparathyroidism
• Underlying malignancy
• Smoking, alcohol
• Premature menopause
• Coeliac disease, hyper/hypothyroidism
• Haematologic disease – multiple myeloma
• Chronic steroid use
• Major organ disease

Question 11

Osteoporosis - complications

Answer 11

• Pain/vertebral instability – management with neurosurgical intervention, metal fixtures
• Spinal nerve or spinal cord compression – MRI spine, neurosurgical intervention
• Atypical femoral fractures post bisphosphonate therapy, osteonecrosis of the jaw
• Prior gastrooesophageal reflux/strictures, CKD, malignancy – bisphosphonate selection
• Prior hip replacements, metalware fixators post fracture

Question 12

Osteoporosis - management

Answer 12

• Weight bearing exercises, physiotherapy
• Calcium and vitamin D supplementations
• Bisphosphonate therapy oral vs. IV, rationale
• DEXA follow up

Question 13

urge Incontinence - management

Answer 13

• Bladder diary, bladder training physiotherapy
• Use of anticholinergics for urge incontinence
• Pessaries for stress incontinence, vaginal prolapse; failed vaginal sling -

Question 14

overflow incontinence - management

Answer 14

Obstructive – prostate – TURPS, superpubic catheter insertion, self catheterisation
- Non-obstructive – self catheterisation
therapies
- Botox therapies

Question 15

General risk factors for frailty

Answer 15

• Age
• Weight
• Comorbid burden – cardiorespiratory disease, osteoporosis and fractures, obesity, T2DM w/ extensive microvascular disease, multiple strokes, parkinsons disease, peripheral neuropathy, CKD
• Recurrent hospital admissions
• Level of care required at home/nursing facility
• Walking aids
• Help with meals
• Showering and toileting
• Dressing
• Exercise tolerance