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MBBS VI Medicine > Geriatrics medicine handbook > Flashcards

Geriatrics medicine handbook Flashcards

1
Q

What is the history taking and PE for altered responsiveness or decreased general condition?

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2
Q

What is the Ix and Mx for altered responsiveness or decreased GC?

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3
Q

How to assess the mental competence of patient in elderly?

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4
Q

What are practical tips to avoid misinterpretation as euthanasia in care of dying?

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5
Q

What are common drugs prescribed in end of life care of older patients?

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6
Q

What is the assessment of DM in older patients?

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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

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7
Q

What are the glycemic targets in older individuals?

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8
Q

What is the treatment principles of DM in elderly?
What is the management?

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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.

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9
Q

What are practical notes to avoid hypoglycemia in elderly DM?

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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
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10
Q

Define fall

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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.

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11
Q

What is the approach to falls?
What is the risks and precipitating factors for falls?

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12
Q

How to do a fall assessment?

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13
Q

How to manage falls (usually multi-modalities)?
What interventions may be ineffective yet harmful?

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  • 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
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14
Q

Compare hypertension between older adults and younger adults

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  • 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
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15
Q

What is the hypertension treatment consideration in older adults?

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  • 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.
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16
Q

What is the musculoskeletal pain assessment in older people?

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17
Q

What are common musculoskeletal disorders in older people?

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18
Q

What is the management principle of MSS pain?
What is non pharmacological management?

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19
Q

What is pharmacological management of MSS pain?
What injection/surgery considerations?

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20
Q

What is important history taking of neurocognitive disorder?

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21
Q

What to do for PE, Ix and reference to DSM5 in neurocognitive disorder?

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22
Q

What is the management of neurocognitive disorders?
Social and medical aspects

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23
Q

What are causes and pathogens for nursing home acquried pnemonia (NHAP)?

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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.

24
Q

What Ix and Mx for nursing home acquired pneumonia (NHAP)?

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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.

25
Q

Define orthostatic hypotension
How to do measurement?
What is the clinical presentation?

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26
Q

What are the causs of orthostatic hypotension?

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27
Q

What is the management of orthostatic hypotesion?
Non pharmacological and pharmacological

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28
Q

What are the principles of pharmacotherapy in old age?
AE, medication adherence and prescription of new drugs

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29
Q

What is important to assess in medication review in suspicion of polypharmacy?

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  • Accurately asceratin all current medication use (in HA, private sector, GOPC, over the counter, traditional chinese medicine)
  • Verifiy current indications for ongoing treatment
  • Stop medications taht are without net benefits (or gradually wean off medications that are likely to cause adverse withdrawal events (BDZ, B blocker, steroid)
30
Q

Relationship between geriatric conditions and causative medications
Fall, urinary incontinence, delirium, syncope, anorexia/weight loss

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31
Q

What is the PE, Ix and Tx for post op delirium?

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32
Q

What is the general management of pressure ulcers

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33
Q

What is the wound assessment and staging of pressure ulcers?

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  • Evaluated for length, width and depth, presence of sinus tracts, exudate and presence of necrotic or granulation tissue
  • Staged according to NPUAP pressure injury stages
34
Q

What is the local wound management for pressure ulcers?

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  • Stage 1 PI: covered with transparent film for protection
  • Stage 2 PI requires a moist wound environmnet. A semiocclusive (transparent film) or occlusive dressings (hydrocolloids or hydrogels) can be used unless there is infection
  • Stage 3 and 4 PI: generally require debridement and coverage with appropriate dressings and possibly treatment of infection
35
Q

What is the wound debridement and wound dressing for pressure ulcers?
When may antiseptics and antimicrobial agents be considered?
Indications for application of negative pressure wound therapy
End of life care

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Wound dressing: protect the wound from contamination and facilitate healing by absorbing exudate and protecting healing surfaces. A moisture retaining dressing, including saline moistened gauze, transparent filsm, hydrocolloids, and hydrogels, should be used to keep moisture for desiccated ulcers.
* Hydrogels to keep moisture for autolytic debridement.
* Foam and low adherence dressings for granulation stage
* Hydrocolloid and low adherence dressings for the epithelialization stage

Antiseptics and antmicrobial agents
* Most topically applied antiseptics asnd antimicrobial products are irritating, partially cytotoxic leading to delayed healing
* 2 of these agents may have potential benefits, including cadexomer iodine and silver based dressing
* Used ony in presence of heavy local contamination.

Negative presure wound therapy (NTWT): enhances wound healing by reducing edema surrounding the wound, stimulating circulation, increasing rate of granulation tissue formation and wound closure. Can be considered as an early adjuvant for the treatment of stage 3 and 4 pressure ulcers.
* Pressure ulcer should be debrided of necrotic tissue prior to the use of NPWT and covered with a foam dressing

End of life care
* Pressure injuries common in terminally ill older patients and the wound is not likely to heal
* Pain management, odour control, and exudate control are indicated for comfort care. Conservative debrideemnt of slough to control the bioburden

36
Q

What to do in the assessment and PE of spasticity?

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37
Q

What is the management of spasticity?

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Identify goal first
* Does patient require treatment? Listen to patients wish
* Aim of treatment: balance pros and cons of treatment
* Will the treatment affect the QoL of patient and carers

Need to consider the following before initiation of treatment
* Duration of spasticity
* Severity of spasticity
* Location of spasticity
* Prior successful intervention
* Current functional status and future goal
* Underlying dx and comorbidities
* Ability to comply with treatment
* Availability of carer and follow up therapy

38
Q

What are oral drugs treatment for spasticity?

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  • BDZ: diazepam (start at 5mcg nocte, can increase slowly up to 60mg/d in divided dose), clonazepam: 0.5mg nocte, up to 20mg/d in divided dose. SE: sedation, weakness, hypotension, memory impairment, tolerance and dependency
  • Baclofen: dosage range from 30-100mg/d in dividied dose. AE: nausea, vomiting, tolerance, seizure, hallucination, cautious use in renal insufficiency
  • Dantrolene: for supraspinal cause e.g. cerebral palsy/traumatic brain injury. Dosage range 25-400mg/d. Dantrolene should not be used with other agents kown to cause hepatotoxicity, including tizanidine. If no benefit after 4-6 weeks of treatment at maximal therapeutic dose –> medication should be discontinued.
  • Tizanidine: for spasticity due to cerebral or spinal damage. Start at 2-4mg/d, nocte, increase dose gradually and slowly. Maintenance dose 18-24mg/d, max 36mg/d. AE: dry mouth, somnolence, asthenia and dizziness
  • Other oral agents: clonidine, gabapentine, lanotrigine, crytoheptadine
39
Q

What is the injection therapy for spasticity?

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40
Q

What is the diagnostic flowchart for syncope?
What are the essential initial Ix to rule out any life threatening causes?
What is important history taking to assess underlying cause?

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41
Q

What is short term high risk criteria (acquired during history taking or Ix) for syncope that requires prompt hospitalization or intensive evaluation?

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42
Q

What are the diagnostic tests according to initial evaluation for syncope?

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43
Q

What is the treatmnet for vasovagal syncope?

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  • Maintain adequate hydration +/-salt supplementation
  • Avoid triggers (hot crowded places, dehydration, cough suppression in cough syncope)
  • For patients with prodromal symptoms: employ isometry muscle contraction (hand grip, leg crossing) to abort episode.
  • Stop or reduce hypotensive drugs, tareting SBP of 140mmHg (class 2a)
  • Fludrocortisone 50-300mg daily
  • Midrodrine 2.5mg bd -15mg tds (S/E: supine HT, bradycardia, piloerection, urinary retention)
  • Dual chamber cardiac pacing: for selected cases (class 2a/2b)
44
Q

What is the history taking for urinary incontinence?

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45
Q

What is PE and Ix for urinary incontinence?

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PE
* General (peripheral edema, diabetes)
* Abd (bladder distension after voiding)
* Pelvic (gynaecological abnormalities, mass, fistula, and skin condition)
* Rectal (perineum sensation, rectal tone, faecal impaction, prostate and mass)
* Neurological (dementai, delirium, stroke, Parkinsons disease and compression, autonomic neuropathy, peripheral neuropathy0

Ix
* 3 days bladder diary
* Urinanalysis and renal function
* Post void residual: indicated if symptoms suggestive of voiding dysfunction and recurrent UTI.
* Other optional tests (urine cytology, imaging, cystoscopy, uroflowmetry, urodynamic study)

46
Q

What is non pharmacological/ pharmacological management of urinary incontinence?
What is the acronym for the reversible causes?

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47
Q

What are the causes of urinary retention?

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48
Q

What is the assessment of urinary retention and the Ix done?

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Assessment
* Mental state, mobility, pain, constipation, signs of UTI, bladder stones or malignancy, neurological examination including DRE
* Drug history
* In men, DRE to assess prostate size and characteristics
* In women, perineal examination for genital prolapse

Ix
* Urinanalysis and RFT
* Imaging of urinary tract (KUB, USG, MRI/CT, cystoscopy should be arranged only if recurrent UTI or suspicious of renal stones, malignancy or other anatomical abnormalities
* PSA testing could be arranged if symptoms suggestive of BOO abnormal prostate during DRE or concerns about prsotate cancer
* Do not routinely arrange post void residual (PVR) measurement, uroflowmetry or urodynamic study at initial assessment

49
Q

What is the management of urinary retention?
General measures, pharmacological and non pharmacological?

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50
Q

What are the different class of drugs that can cause urinary retention?

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MBBS VI Medicine (92 decks)

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