Geriatrics medicine handbook Flashcards
(50 cards)
What is the history taking and PE for altered responsiveness or decreased general condition?
What is the Ix and Mx for altered responsiveness or decreased GC?
How to assess the mental competence of patient in elderly?
What are practical tips to avoid misinterpretation as euthanasia in care of dying?
What are common drugs prescribed in end of life care of older patients?
What is the assessment of DM in older patients?
Comprehensive geriatric assessment approach in particular: Cognition
Gait and balance
Frailty syndrome – gait speed and muscle strength
Vision
Mood
Social reserve
Hand dexterity
And other standard complication assessment in adults in the absence of established complications
What are the glycemic targets in older individuals?
What is the treatment principles of DM in elderly?
What is the management?
Treatment principles
* Prevent acute complications of profound hyperglycemia
* Avoid hypoglycemia
* Delay chronic complication but not applicable if already established or in the presence of limited life expectancy
Management
Diet and weight control: aim at weight stabilization
SMBG (self monitoring of blood glucose): not routinely advised to monitor post prandial hyperglycemia but sometimes indicated to detect fasting or pre-meal hypoglycemia
Pharmacotherapy
* Metformin is preferred initial therapy if no contraindications (eGFR <30ml/min or at risk of lactic acidosis)
* Short acting sulphonylurea to minimize the risk of hypoglycemia
* Alpha-glucosidase inhibitor is safe for hypoglycemia and good for postprandial hyperglycemia but potency is ow
* Adverse profile of TZD with particular concerns in old age are: water retention, edema and heart failure, fragility fractures and possible bladder cancer
* Incretin based therapies such as DPP4 inhibitors and GLPr agonists have low risk of hypoglycemia and are good to counteract post-prandial hyperglycemia
* In general, insulin therapy for frail older adults should be simple and 1/2 daily dose intermediate acting insulin is sufficient. Consider long acting basal insulin analogue (glargine or detemir) with or without pre-prandial rapid-acting insulin analogue (lisopro and aspart), which are reserved only for those with wide glycemic excursion.
What are practical notes to avoid hypoglycemia in elderly DM?
Preferred therapy
* Metformin
* Incretin based therapy (low risk of hypoglycemia)
* Glucosidase inhibitor (low potency)
* Long acting basal insulin analogue
- Hypoglycemia can blunt glucose counter regulatory response to subsequent hypoglycemia, leading to recurrent hypoglycemia. Loose control for 2-3 weeks is advised for restoring the counter regulatory response
- Infection related hyperglycemia may need escalation of insulin therapy to counteract the activation of stress hormones
- Consider continuous glucose monitoring study when asymptomatic hypoglycemia, which is common in old age, is suspected
Define fall
Defined as an event that results in the patient or a body part of the patient coming to rest inadvertently on the ground or other surface lower than the body. Fall results in injuries, more hospitalizations, clinic visits and emergency attendance. Moreover, fear of falling, loss of confidence in walking, social isolation and depression can occur.
What is the approach to falls?
What is the risks and precipitating factors for falls?
How to do a fall assessment?
How to manage falls (usually multi-modalities)?
What interventions may be ineffective yet harmful?
- Medication review and minimization (in particular psychotropic drugs). Use standardized tool such as the Beers criteria for potentially inappropriate medication use in older adults and STOPP for drug reconciliation
- Treatment of cardiovascular RF. Treat underlying cardiovascular causes e.g. carotid sinus hypersensitivity, vasovagal syndrome, orthostatic hypotension, postprandial hypotension), arrhythmias
- Strength and balance training
- Home and environmenal hazard modifiation
- Foot and footwear check and modifications
- Vit D and calcium supplementation
- Correction of vision
- Strengthen bone to reduce fracture even when falls occur
- Hip protectors
- Safety alarms
- Restraints increase risk of delirium in the hospital and the resulting immobilization are associated with pressure ulcer occurence, resp complications, and death via strangulation and asyphxia
Compare hypertension between older adults and younger adults
- Isolated systolic hypertension (SBP >160 while DBP <90mmHg) mostly occur in older patients
- Changes of structure and function of vascular tree make them more prone to hypotension e.g. postural change or meal ingestion; in response to medications and during volume contraction
- Antihypertensive medications can worsen postural hypotension and put vulnerable older adults at a greater fall risk
What is the hypertension treatment consideration in older adults?
- Life style modificatin: diet and weight control (balanced against compromising quality of life)
- Adoption of lower SBP treatment goal (130-140mmHg) may be considered in age of 65-80 with little comorbidity and biologically young. Otherwise less stringent <150mmHg should be used for people >80 or older people with multiple comorbidities and biologically old.
- DBP target is <90mmHg. An increased ris of ACS associated with DBP between 61-70mmHg and increased further at DBP <60mmHg, likely due to myocardium hypoperfusion which is diastrolic phase deendent
- First one-2 months of anti HT therapy in older patients associated with increased risk of falls and hip fracture. Therefore start low (initial odse is approx half that in younger adults) and go slow (achieve target BP over a period of week sto months). unless in hypertensive emergency to minimize the risk of postural hypotension.
What is the musculoskeletal pain assessment in older people?
What are common musculoskeletal disorders in older people?
What is the management principle of MSS pain?
What is non pharmacological management?
What is pharmacological management of MSS pain?
What injection/surgery considerations?
What is important history taking of neurocognitive disorder?
What to do for PE, Ix and reference to DSM5 in neurocognitive disorder?
What is the management of neurocognitive disorders?
Social and medical aspects
What are causes and pathogens for nursing home acquried pnemonia (NHAP)?
Aspiration plays an important role in the causation of NHAP. Risk factors include advanced dementia, old CVA, GERD and poor oral hygiene.
Causative agents
Respiratory viruses (Influenza A and B viruses, and RSV), Gram negative bacilli (GNB) and Staphylococcus aureus are more frequently isolated in NHAP compared with CAP.
Mycobacterium tuberculosis should be considered in view of its endemicity in HK.
Streptococcus pneumoniae and Haemophilus influenzae are also common bacterial culprits.
Atypical pathogens are less commonly implicated in NHAP than CAP.
What Ix and Mx for nursing home acquired pneumonia (NHAP)?
Ix
CXR: clear image indicates simple aspiration without pneumonitis (chemical inflammation of lung parenchyma without infection) or pneumonia (infection)
Sputum: routine bacterial cultures, and AFP smear and cultures
NPA: rapid test, such as by IF, should be considered for infection control and discharge planning
Treatment
Non pharmacological: keep good oral hygience, consult dental surgeon for dental caries, prop up patients during feeding. PT for chest excercise, drainage and collection of sputum specimens.
Emperical antibiotic treatmnets
Empirical broad spectrum antibiotics in patients with history of MDR bacterial pneumonai e.g. vancomycin for MRSA and ertapenem for ESBL producing GNB.
Empirical anti viral agents, such as oseltamivir and amantadine, should be considered when viral infection is suspected, especially if outbreak of influenza like illnesses in nursing home is reported.
Report to CGAT (community geriatric assessment team) if outbreak of viral infection in nursing home is suspected or confirmed.
