Yr4 Geriatrics - Lectures Flashcards

Question

Which investigations would you consider as part of a CGA? (10) - What is the overall purpose of a CGA?

Answer 1

**Investigations** - No routine blood or radiological tests for a CGA - Consider (if indicated): 1. U&Es 2. FBE 3. LFTs 2. Glucose 2. TFTs 3. Vit D 2. B12, folate 3. Urine (dipstick, MCS) 4. ECG 5. CXR

Answer 2

**Management Plan** - Developing person-centred goals (SMART) - Often involves a family meeting. - A CGA often reveals multiple issues. - Common examples: 1. Sub-optimally managed medical problems 2. Polypharmacy (including medication side effects and drug interactions) 3. Functional impairments 4. Geriatric syndromes (frailty, dementia, falls, incontinence, pain)

Answer 3

**Geriatric Syndromes** - “Syndrome”: recognizable set of symptoms and signs which indicate a specific condition for which a direct cause is not necessarily understood. Does not fit into a discrete organ-based disease category. - Recognition of the importance of other syndromes affecting older persons such as frailty and polypharmacy. - Geriatric Giants (1965, Isaacs): 1. Immobility 2. Instability (falls), 3. Incontinence 4. Impaired intellect/memory (including delirium and dementia).

Answer 4

**Frailty, a clinical syndrome** - Defined by ANZSGM Position Statement 22 ’Frailty in Older People’ - The term frail is intended to identify vulnerable older people at high risk of adverse outcomes including falls, worsening disability, institutionalisation and death. - Frailty is not synonymous with either age or disease. - Conceptualised as an age-related syndrome of physiological decline characterised by an increased vulnerability to adverse health outcomes. - Frailty may coexist with chronic disease, multimorbidity, and/or disability – but does not need to. - Clinical frailty scales exist – but clinical impression is often the best way to identify a frail older person. - Definition still contentious.

Answer 5

- Delirium is a syndrome. - Family or friends may say the patient is “not normal”, “confused”, can’t concentrate. - Patients may say: “I don’t feel quite right” “I can see funny things on the walls” “Where am I again?” - Patients may be confused, hit out, or do nothing. - Behaviours can change from hour to hour, day to day. - This condition has had many different names including acute confusional state, metabolic encephalopathy and acute organic brain syndrome. The term delirium has largely replaced these.

Answer 6

1. Acute/subacute onset (hours/days). 2. Fluctuation (symptoms come/go, or vary in intensity over the day). 3. Decreased attention (distractible, cannot focus or shift). 4. Altered level of consciousness (hyper alert versus drowsy versus difficult to rouse versus unrousable). 5. Disorganised thinking (may be rambling, tangential, incoherent). 6. Altered sleep-wake cycle. 7. Perceptual disturbance– may have visual hallucinations or delusions (typically persecutory, may be grandiose). 8. Emotional deregulation (anxiety, fear, irritability). 9. Psychomotor disturbance.

Answer 7

1. Hyperactive 2. Mixed! (most common) 2. Hypoactive! - More common in older people. - Often missed. - Has a worse prognosis than other subtypes of delirium, including worse long-term cognition when delirium has a longer duration.

Answer 8

1. Patients aged **65 and older** 2. With known **cognitive impairment** 3. With known **dementia** - One of the strongest, most consistent risk factors. Underlying dementia is present in 25-50% of patients. Presence of dementia increases risk of delirium by a factor of 2-3 x. 4. With a **hip fracture** 5. Those who are **severely ill** or at risk of dying 6. **Previous episode(s)** of delirium.

Answer 9

**Assess for delirium in:** - Patients with cognitive impairment on presentation to hospital. - Patients who have a sudden decline in cognitive function or change in behaviour during their hospital admission. - Delirium is less likely to be recognised in patients with frailty or dementia.

Answer 10

**Screening Tools** 1. Abbreviated Mental Test score - Traditional AMT (10 questions) + AMT4 2. 4A test (4AT) 3. Single Question in Delirium (SQID) - (asking family or friend): Do you think [name of patient] has been more confused lately? Yes/No answer 4. Confusion Assessment Method NOT * Mini Mental State Examination * Montreal Cognitive Assessment (MoCA)

Answer 11

**4AT components - Four sections** 1. Alertness 2. AMT4 3. Attention 4. Acute change or fluctuating course Score out of 12, anything greater than 4 is abnormal, anything 1-3 possibly abnormal.

Answer 12

- If features 1 and 2 present AND - Feature 3 OR 4 present - Delirium present according to CAM. - Serial assessments can track progress/recovery. - A large (N=785) RCT comparing the 4AT and the CAM found that the 4AT had higher sensitivity than the CAM, and a similar specificity.

Answer 13

**Epidemiology of Delirium** - 10 - 31% of new hospital admissions. - Up to 30% of medical patients >65 years will develop delirium during hospital admission. - Prevalence in ICU patients up to 80%. - Prevalence of post-operative delirium: 5-10% general surgery, 50% orthopaedics. - Around 80% will develop delirium near death. - In hip fracture patients, delirium can occur in up to 53.3%. - In patients aged 70 and over, up to 18% will develop delirium during admission.

Answer 14

**Dementia** - Delirium can be mistaken as worsening of dementia. - Delirium should still be treated!!! **Psychiatric Illness** - Hypoactive delirium can be mistaken as depression. - Agitation and hallucinations can be mistaken as schizophrenia.

Answer 15

1. Sepsis and infections (especially chest and urine) 2. Hypoxia 3. Constipation 4. Medications 5. Alcohol and nicotine withdrawal 6. Uncontrolled pain 7. Surgery/procedures 8. Sleep deprivation 9. Disorientation (e.g. constant bed moves) 10. Sensory deprivation (e.g. loss of glasses/hearing aids)

Answer 16

**Delirium Evaluation** 1. Suspect 2. Recognise 3. History (including medication review) - Collateral important. 4. Physical examination (including neurological) - May not be cooperative. 5. Investigations - 'Normal' investigations do not exclude delirium.

Answer 17

**Delirium Prevention** - Preventative measures can reduce delirium incidence. - 30 – 40% of delirium cases in hospital can be prevented. - A non-pharmacological, multi disciplinary approach (environmental strategies) has been shown to reduce the incidence, duration and severity of delirium. - Little evidence for pharmacological strategies to prevent delirium.

Answer 18

**TREATMENT PRINCIPLES** 1) Protect/support the patient 2) Treat any underlying cause(s) **What are we trying to achieve?** 1. Prevent injury 2. Prevent falls 3. Avoid pressure injuries, malnutrition, dehydration. 4. Continue appropriate treatment 5. Enhance recovery. 6. Return to normal function.

Answer 19

**Everyone has a role in management of delirium (multidisciplinary team).** - Good nursing care, - medical review for complications, - mobility with physiotherapy, - dietician review for nutrition, - speech pathology review for swallow, etc. **Environment** - Direct vision room (near the nurses' station). - Delirium unit/pod. - Appropriate noise (keeping it quiet may help) - Appropriate lighting (well lit) - Single room if possible. - Familiar objects. - Clear signs (day, time, place) - Low bed?

Answer 20

**Caution** - Use medication only if patient is distressed or there are behavioural risks - Avoid benzodiazepines because they generally worsen delirium and may cause falls - Antipsychotic medications are not a fir st line option and should be used with caution because of an association with strokes and adverse cardiac events

Answer 21

THE COMPLAINT OF ANY INVOLUNTARY LEAKAGE O F URINE

Answer 22

**Requirements** 1. Mobility 2. Motivation 3. Cognition 4. Manual dexterity, 5. Functionally intact urinary tract. Normal voiding requires complex neural co-ordination to alter from urine storage in the bladder to voiding (at socially acceptable times).

Answer 23

**Voiding mechanism (Micturition Reflex)** - Parasympathetic increases, Sympathetic decreases = Bladder contracts & Relaxes internal (involuntary) urethral sphincter - Somatic tone decreases (pudendal nerve) = External urethral sphincter (within pelvic floor) relaxes and opens. (voluntary sphincter). - At its simplest (seen in infants), micturition is an autonomic reflex at the spinal cord level. **Pathway** 1. Stretch receptors detect filling of bladder. 2. Afferent signal to spinal cord segments S2-3. 3. Signals return to bladder via parasympathetic fibres in pelvic nerve. 4. Efferent signals excite detrusor muscle to contract. 5. Efferent signals relax internal urethral sphincter. 6. Urine involuntarily voided if not inhibited by the brain.

Answer 24

**Medical** 1. UTI and Urosepsis 2. Falls 3. Fractures 4. Pressure Injuries 5. Skin and Perineal Rashes (including cellulitis, dermatitis) **Psychosocial** 1. Social isolation 2. Stigmatisation 3. Embarrassment, Depression 4. SleepDeprivation 5. Sexual Dysfunction 6. Caregiver Stress, 7. Institutionalisation Risk

Answer 25

**Established Incontinence** - The result of pathophysiological (non-neurogenic or neurogenic) mechanisms. 1. **Detrusor Overactivity**: Cystitis, cancer, stones, urethral obstruction, MS, stroke, Alzheimer's, Parkinson's. 2. **Detrusor Underactivity**: Idiopathic, chronic outlet obstruction, autonomic neuropathy, surgical damage, disc compression, plexopathy. 3. **Outlet Obstruction**: Prostate (BPH, cancer), urethral stricture, spinal cord lesion with detrusor-sphincter dyssynergia. 4. **Outlet Incompetence**: Prostate surgery, urethral hypermobility, sphincter incompetence, radical prostatectomy with nerve damage.

Answer 26

1. Anticholinergics (urinary retention) 2. Cholinesterase inhibitors (incontinence) 3. Calcium-channel blockers (constipation - retention, fluid retention) 4. ACE-inhibitors (cough – stress incontinence) 5. Diuretics (diuresis) 6. Sedatives (including alcohol) (functional) 7. Alpha-blockers (urethral relaxation), alpha agonists (men) 8. Beta-agonists (urinary retention) 9. Narcotics (constipation - retention, sedation) 10. Psychotropics

Answer 27

**Considerations** - In frail, older people, think outside the bladder i.e., consider functional factors. - Symptoms do not always correlate with underlying pathology. - Urinary retention can occur because of either outflow obstruction or a non-contractile detrusor. - A normal sized prostate on PR and PVR does not absolutely exclude obstruction. - No agreed volume of PVR diagnostic of retention (although 200mL is often used). - Urodynamic studies may help confirm/exclude obstruction.

Answer 28

**Urogynaecological Examination** - Should only be undertaken with the consent of the patient and a chaperone must always be present. - It is generally recommended that a male doctor should have a female chaperone present (staff/family). - Will usually be part of the work-up in a specialised Continence Clinic (not performed routinely in the ward setting). - This examination should not be performed by someone who does not have the expertise to do so.

Answer 29

**Other investigations as needed** 1 - Ultrasound/CT (KUB) 2 - Urodynamics - Complex patients. - Not responding to treatment. - Previous pelvic surgery or radiation. - Younger patients, especially if diagnosis uncertain. - Surgery being considered - not all cases. 3 - Cystoscopy

Answer 30

- **Urinary Tract Infection** = Infection in any part of the urinary tract (kidney, ureters, bladder, urethra). Typically, lower tract. - **Stress Incontinence** = Involuntary leakage of urine on stress or exertion. Usually due to weakness of the pelvic floor muscle and fascial support, or weakness/damage to the urethral sphincter. - **Urgency** = Abrupt, strong, often overwhelming, need to urinate. Occurs when the pressure in the bladder increases suddenly, whether or not the bladder is full.

Answer 31

**Continence Management** Set realistic treatment goals in discussion with the patient and/or carer. In frail, older people sometimes cure is not possible. Contained Incontinence (uses pads or appliances) or Dependent Incontinence (dry with regular toileting, medications, or behaviour treatments) may be the goal. **Treatment Considerations** 1. Nature of the predominant symptoms (stress versus urgency) 2. Expectations. 3. Level of patient commitment to therapy. 4. Tolerance/risk of adverse effects. 5. Financial considerations.

Answer 32

**Fluid management (How much do we recommend?)** - Frequent intake of small amounts of fluid (120 - 150mL per hour) up to 2L per day total. - Avoid large, episodic fluid boluses. - Law of Laplace: Bladder more likely to contract at smaller bladder volumes. - Encourage drinking, not withholding fluid! - Consider comorbidities e.g., heart failure.

Answer 33

**Anticholinergics** - No direct comparison studies of medications used to treat UI for efficacy or adverse effects. - Most studies have been short-term industry sponsored studies, comparing to placebo. - Anticholinergic side effects: Dry mouth, blurred vision, urinary retention, constipation, confusion (especially in older persons). Warn patients/carers. - Check PVR before starting therapy.

Answer 34

**Examination Findings (In Hospital)** - Temperature 37.8 degrees C. - Pulse rate 82 bpm. - BP 130/85. - SaO2 98% RA. - Abdominal examination - mild suprapubic tenderness to palpation. - Neurological examination unremarkable. - Fluid status - mild peripheral oedema, chest clear. JVPNE. - Bowels open regularly after aperients prescribed. - Diagnosis UTI, prescribed antibiotics, discharged home with follow-up in Continence Clinic.

Answer 35

**General and behavioural measures:** - Aperients for constipation. - Dietary advice for bowels. - Bladder training. - Pelvic floor muscle exercises. - Referral to continence physio and dietitian. - Fluid advice - smaller amounts frequently up to 1.5L/day. - Monitor fluid status with GP/ cardiologist - aim euvolaemia, avoid dehydration. - Topical vaginal oestrogen cream (treat atrophic vaginitis) - not systemic (no efficacy and may worsen incontinence).

Answer 36

**Urinary Catheterisation** - Types of catheters: 1. Indwelling (IDC) 2. Suprapubic (SPC) 3. Intermittent self-catheter (IMC) - Short-term IDCs are commonly used in hospital for management of acute urinary retention (AUR), bladder irrigations, peri-operative setting. - Individuals presenting with AUR may require an IDC to remain in situ for several days before attempting a trial of void (TOV). This allows the bladder to regain its tone. - Multiple failed, appropriately timed, voiding trials warrant specialist referral.

Answer 37

**Long-term IDC** - Ideally, a long-term IDC should be avoided for incontinence management. - An IDC is not a substitute for good nursing care. - In rare situations, when a suprapubic catheter (SPC) is contraindicated and other continence management methods have failed, a chronic IDC may be needed. - Safe community practice recommends that IDCs are changed every 4–6 weeks. - Scheduled IDC changes may vary according to individual needs. However, IDC changes should never persist beyond three months.

Answer 38

Consider specialist referrals: 1. Gastroenterologist 2. Dietitian 3. Continence Nurse 4. Continence Physiotherapist 5. Colorectal specialist

Answer 39

**Osteoporosis** - Low bone mineral density (BMD) and microarchitectural deterioration of bone tissue. - i.e., Reduced bone quantity and bone quality. - Leads to decreased bone strength, increased bone fragility, and increased risk of fracture. - Osteoporotic fractures usually occur from a fall from standing height (or less). Minimal trauma.

Answer 40

**Measuring Bone Density - DXA Reporting** - BMD is usually reported as a T-score (number of standard deviations (SDs) of the BMD measurement above or below that of young healthy adults of the same sex).

Answer 41

**Epidemiology of Osteoporosis** - All persons lose bone with advancing age. - Bone loss is accelerated in women after the menopause, and in older men due to declining sex hormone levels and reduced physical activity. - Based on WHO criteria (T-score reference values): - Aged >70 years: 13% of men and 43% of women osteoporotic, 55% of men and 49% of women osteopaenic. - Aged 50-69 years: 3% of men,13% of women osteoporotic.

Answer 42

**Fractures - Epidemiology** - Incidence of fracture increases with age (both sexes). - > 70% of all fractures occur in those ≥70 years. - Approximately 70% MTF occur in women. - Lifetime risk of MTF in women aged >60 yrs is approximately 44%. - Types of fracture: - Ages 50-69: non-hip, non-vertebral most common. - Hip fractures and vertebral fractures more common >70 years of age.

Answer 43

Suspicion for Vertebral Fracture Based on: 1. Height loss of 3cm or more. 2. Thoracic kyphosis. 3. New onset back pain suggestive of fracture.

Answer 44

**Other medical history of relevance** 1. Reflux oesophagitis 2. Dental/periodontal disease (date of last review) 3. Breast cancer. 4. Renal impairment 5. Atypical fractures.

Answer 45

**Measuring Bone Density: Consensus statement** - In all Australians aged ≥70 years and in most Australians aged ≥50 years with a fragility fracture, a bone density test is recommended. **Groups to Consider** 1) Postmenopausal women and men older than 50 years of age diagnosed as having at least one minimal trauma fracture (equivalent to a fall from standing height or less). 2) Postmenopausal women and men older than 50 years of age diagnosed with osteoporosis (defined as a T-score of –2.5 or less) but without evidence of a minimal trauma fracture. 3) Postmenopausal women and men greater than 50 years of age at risk of minimal trauma fracture based on history.

Answer 46

**Osteoporosis: General management** 1. Address lifestyle risk factors(smoking, alcohol, sedentary lifestyle). 2. Exercise (weight-bearing). 3. Calcium plus/minus vitamin D. 4. Antiresorptive therapy (first-line): - Bisphosphonate or denosumab. 5. Other drugs as indicated: HRT, SERM, anabolic. Discuss medication side effects. 6. Consider referrals: Falls clinic, Endocrine clinic, Dietitian, Dental clinic/own dentist.

Answer 47

(1) Minimal Trauma Fractures - Consensus Statement - There is an urgency to treat patients with prevalent or recent fragility fractures. - This includes patients with osteopaenia (the majority of patients with fragility fractures) because the risk of subsequent fractures is increased, especially in the next 12-24 months.

Answer 48

**(3) No history of minimal trauma fracture (≥ 50 years of age).** - Consider DEXA (spine and proximal femur) based on risk factors (number and type). - Estimate absolute fracture risk (FRAX and Garvan calculators). - High 10-year risk of fracture Hip fracture >3%, any fracture >20% (OR T score ≤ –2.5 on DXA scan) then initiate treatment with anti-osteoporosis medication. - Low risk of fracture, treatment not recommended. - Address lifestyle risk factors for all.

Answer 49

**Calcium and Vitamin D - Evidence of benefit** 1. Beneficial effects on BMD: Calcium, vitamin D, both 2. Reduced fracture risk: Calcium and vitamin D, calcium (not vit D alone) 3. Improved muscle strength (and therefore falls prevention): Vitamin D

Answer 50

- Avoid immobilisation and daily weight bearing exercise is encouraged. - Moderate to high intensity progressive resistance and impact training increases bone density, maintains muscle mass and strength, and mobility to reduce falls. - A recent Cochrane Review showed exercise reduced the rate of falls in older adults by 23%, and the number of individuals with fractures by 27%, with a trend to a decrease in fractures.

Answer 51

**First-line anti-resorptive therapy** - 3 drugs fulfil the requirement of evidence for reduction in spine, hip and non-vertebral fractures: 1. Risedronate 2. Denosumab 3. Zoledronic acid - Alendronate reduces vertebral and hip fractures but the evidence for non-vertebral fracture risk reduction is less robust. - Therefore, first-line therapeutic options include: 1. Bisphosphonates (risedronate, zoledronic acid and alendronate) 2. Denosumab

Answer 52

**Bone turnover markers** - Fasting metabolic bone study (bone turnover highest early morning and food suppresses markers, especially resorption). Blood and urine. - Non-invasive method to assess bone remodeling. - Usefulness is debated. ? Role for monitoring compliance/effects of Rx. - Reimbursed under Medicare for GP use in patients with osteoporosis (once per year).

Answer 53

**Bone turnover markers** - CTX and NTX (C and N-terminal telopeptide of type 1 collagen) – bone resorption. - P1NP (amino-terminal pro-peptide of type 1 collagen) and ALP– bone formation. - Most important role is measuring short-term (3-month) responses to oral bisphosphonates and anabolic drugs (Impractical to repeat BMD <2 years).

Answer 54

**Oral bisphosphonate** - Best evidence for risedronate (and alendronate). - Regular review and assessment with long-term use of oral bisphosphonates is required to monitor compliance, occurrence of fractures despite treatment, and side effects. - Enteric coated risedronate has the advantage of a lower risk of upper gastrointestinal irritation (and can and should be taken with food). - Monitoring of BMD should be done no more often than 2-yearly (changes at one year are usually small and may not differ from the measurement error). - PBS restricted benefit (age >70 and T score -2.5 or less; or MTF; or corticosteroid-induced osteopaenia/ osteoporosis).

Answer 55

**Other Options: SERMs (Raloxifene)** - Can be considered for treatment in early/post-menopausal women. - No evidence for prevention and reduction of non-vertebral and hip fractures. - May be indicated in women with spinal osteoporosis and a past or family history of breast cancer. - Reduces only vertebral fractures.

Answer 56

**Choice of first-line agent: Bisphosphonate vs. denosumab?** Advantages of oral bisphosphonates: 1. Long-term safety and fracture prevention data. - 10 years alendronate, 7 years risedronate, 6 years ZA. 2. Least expensive pharmacological option. 3. Not associated with increased risk of vertebral fracture with discontinuation of treatment or missed doses (as may occur with denosumab – fully and rapidly reverses effects on bone markers BMD upon stopping, increases fracture risk). 4. Residual fracture benefits persist even after stopping treatment. Continue for act for years after discontinuation.

Answer 57

**Duration of treatment: Bisphosphonate in the setting of high fracture risk** High risk for further fractures: - Osteoporotic fracture before or during Rx and/or - T-score ≤ -3.0 in the absence of fracture. - Continue Rx for up to 10 years (alendronate) 6 years (zoledronic acid) 7 years (risedronate) as clinical trial data show maintenance of BMD and # benefits with no significant increased risk adverse events.

Answer 58

**Duration of anti-resorptive treatment with denosumab?** - No role for drug holiday (unlike bisphosphonate). - Need for indefinite treatment needs to be discussed. - Increased risk of bone loss and vertebral fractures after discontinuation or delay in denosumab injections. - Data out to 10 years – benefit shown (maintenance of BMD with continued treatment for 10 years). **When to repeat DXA scan** = 2 years after starting treatment - No benefit from more frequent monitoring. - Hip and spine BMD. - Consider less frequent monitoring if BMD stable or improved.

Answer 59

**Medication-related osteonecrosis of the jaw** - Defined as an area of exposed bone in the maxillofacial region that has persisted for more than eight weeks, in a patient receiving bisphosphonates, denosumab (or anti-angiogenic therapy for cancer). No history of radiation therapy or obvious metastatic disease to the jaw. - Aetiology uncertain. - Related to dose and duration of treatment. - Related to pre-existing oral disease, surgery, genetics. - Prevalence between 1 and 10 cases per 10,000 in patients receiving oral bisphosphonate (21 cases per 10,000 after 4 years of treatment).

Answer 60

**STROKE**: Neurological injury as a result of disruption of blood supply by embolism, thrombosis, atheroma or haemorrhage. **Clinical Guidelines for Stroke Management 2017** * Pre-hospital care * Early assessment and diagnosis * Acute medical and surgical management * Secondary prevention * Rehabilitation * Managing complications * Discharge planning and transfer of care * Community Participation and long-term care

Answer 61

PATHOLOGY OF STROKE 1) Infarct - Thrombus - Embolus - Lacune 2) Haemorrhage - SAH - Intra-parenchymal (hypertension) - Subdural - Extradural

Answer 62

**Delirium prevention strategies** - It is possible to prevent delirium in at risk patients. - Up to 30 – 40% of delirium episodes may be prevented. - There are several strategies that could be adopted to prevent delirium (Australian, NICE, HELP guidelines).

Answer 63

1. Lighting appropriate to time of day 2. Quiet environment especially at rest times 3. Provision of clearly visible clock and calendar 4. Encourage family/carer involvement in care if appropriate 5. Encourage family/carer to bring in personal and familiar objects 6. Avoid room changes

Answer 64

**Diagnosing Delirium** - Delirium is a clinical diagnosis made on the basis of thorough history taking and physical examination. - Various screening tests could be utilised to detect delirium. - Examples of some of the screening tests include – 4AT score, short Confusion Assessment Method (short CAM), Delirium rating scale revised – 98 (DRS-R-98). - A formal diagnosis can be made by using the DSM –IV criteria or ICD 10. - Once delirium is diagnosed, every attempt should be made to identify the cause or precipitating factor.

Answer 65

- History and physical examination will usually guide further investigations. - If there is no obvious precipitant identified, it is reasonable to perform some screening tests – FBP, U&Es, LFTs, Calcium, CRP, Urinalysis (and MSU if urinalysis abnormal), Chest Xray and ECG. - CT head should not be done routinely unless there is a reason like falls, focal neurology or use of anticoagulation. - Other tests that could be considered further include: blood gases, thyroid function, vitamin B12, lumbar puncture with CSF analysis and EEG.

Answer 66

**Management of Delirium** - Delirium is most effectively managed with multidisciplinary team approach (nursing, PT, OT, dietitian, speech, SW). - Symptomatic and supportive management include both non-pharmacological strategies and pharmacotherapy. - Non-Pharmacological Strategies – should be utilised first in all patients with delirium and these include all the strategies outlined in the in the ‘Prevention of Delirium’ section. - Identification, Modification and Management of predisposing and precipitating factors.

Answer 67

- Recovery might be rapid, but complete resolution can take weeks (sometimes months). - Can be associated with an irreversible decline in physical or cognitive function (RACF placement, increased mortality). - Consider the 3D’s (dementia, depression) in DDx. - Avoid physical restraint – aggravates agitation, leading to injuries and falls. - Non-drug measures should be sufficient for occasional, temporary agitation which does not compromise the care of self or others. - Main approach is nursing/carer based. - Drugs only if non-drug failed or insufficient. - Risk of harm to self or others. - Antipsychotics and BZD can worsen delirium.

Answer 68

- Inadequate hydration can cause or worsen and prolong delirium. - Associated with increased morbidity and mortality among older people. - Thirst response to fluid depletion/inadequacy is altered in older persons. By the time they feel the thirst, they are dehydrated already. - Owing to continence and mobility issues, older adults usually self limit fluid intake. - Important to recognise the signs of dehydration. - Classical signs of dehydration like loss of skin recoil, thirst and orthostatic hypotension are less sensitive in older persons. - Dry oral mucosa may be a better indicator. - Dehydrated older adults presents with atypical signs like confusion, constipation and falls. - Fluid charts – often unreliable indicators of intake.

Answer 69

**Ensuring adequate hydration** - Educate older adults on dehydration risks - Verbal prompting to drink in between meals - Teach older adults not to wait to feel thirsty to drink - Teach them to drink regularly throughout the day - Make fluids easily accessible - Serve fluids at a temperature the individual prefers - Encourage water with all meals - Promote intake of medications with fluids - Boost the flavour of water by adding drops of lemon/ lime juice - Limit fluid intake one to three hours before bed - Reassure that adequate hydration will not have an effect on their continence Avoid or minimise caffeinated, carbonated or alcoholic drinks – increases risk of dehydration

Answer 70

- Normal bowel function varies from person to person (from 3 bowel motion/day to bowel movement once every 2-3 days). - Constipation is a very common problem in older adults. - It is associated with major healthcare costs and affects health related quality of life.

Answer 71

Presentations with constipation in older persons – varied. 1. Confusion 2. Overflow diarrhoea (beware) 3. Abdominal pain 4. Urinary retention 5. Nausea 6. Loss of appetite. Constipation could be caused by primary colorectal dysfunction (slow transit constipation, dyssynergic defecation or Irritable Bowel Syndrome with predominant constipation) or secondary causes.

Answer 72

**Evaluation of Constipation in the Elderly** - Thorough history and physical examination to rule out secondary causes. - Enquire about red flags (weight loss, bleeding, anaemia, family history of bowel cancer). - Review of medications and chronic medical conditions causing constipation is essential part of evaluation. - Abdomen and per rectal examination is a must while assessing patients with constipation.

Answer 73

- Diet and Fibre – increases stool bulk causing colonic distension and promotes stool propulsion. - Recommended daily fibre intake is 20-35gm. - The effect of fibre on bowel movements takes several weeks. - Bloating and flatulence are the main side effects

Answer 74

- Keep an accurate bowel chart (time, amount, consistency – Bristol Stool Chart) - Management of constipation is largely empirical. - No evidence of aperient class superiority. - Rapid relief of constipation – suppositories, enemas, macrogol or saline laxatives to clear the rectum then ongoing management.

Answer 75

**Paracetamol** - Start paracetamol regularly in all patients with persistent pain unless contraindicated (liver failure/ insufficiency). - Maximum daily dose should not exceed 4gm/24 hours.

Answer 76

**Neuropathic pain medications** - Can be trialled if there is evidence of neuropathic pain. Examples include gabapentin, pregabalin (amitryptiline is in the category). - Amitriptyline is an anticholinergic and is generally not used in older patients. - Other antidepressants like SSRIs and SNRIs (duloxetine) can be used for treatment of neuropathic pain. - Pregabalin and gabapentin are effective in treatment of neuropathic pain in older adults, but caution should be taken while prescribing due to risks of adverse effects – dizziness, drowsiness, fatigue etc - Starting dose – Pregabalin – 25mg BD and gradually up titrate, Duloxetine 30-60 mg daily

Answer 77

- Tapentadol has an enhanced tolerability profile (compared to other opioids) – especially suitable for treating chronic pain in older persons. - Tapentadol has only weak effects on serotonin uptake (unlike tramadol). - Tramadol avoided in elderly (confusion)

Answer 78

- Older patients generally need lower opioid doses. - “Start low and go slow”. - Check (+ double check) your dose equivalents. - Hydromorphone sounds like morphine = RISK! - Patches need time to build up (e.g. fentanyl patch 24-72 hours until max effect). - Constipation can occur with opiate use. Begin laxatives at time of starting. - Withdrawal symptoms can occur if stop suddenly. - Regular dosing is better than PRN. - Know the pharmacology of your opiate of choice.

Answer 79

Clear evidence of headstrike - For CT within 1 hour - For CT within 8 hours

Answer 80

**Witnessed fall, NO headstrike** - If the patient had a witnessed fall, and did NOT hit their head and do not need a CT scan of the brain: - CT brain only required if signs of neurological impairment develop (neuro obs)

Answer 81

**Extremities** - Guided primarily by physical examination. If clinical evidence of injury, consider plain X-rays of extremities to rule out fracture. In particular, be suspicious for hip fracture and vertebral fracture. **Otherwise** - Neurological observations as per falls pathway. Re-review and investigate if clinical concern.

Answer 82

**Sleep - Clinical Pearls** - Older people spend more time in lighter sleep stages (with periods of wakefulness) and nap. - Review drugs contributing to disturbed sleep (e.g. drugs causing nocturia, nightmares, stimulants). - Non-drug treatments are first line – use sleep hygiene and other interventions to encourage good sleeping habits. - Sleep hygiene (avoid daytime naps, use bed for sleep or sex, avoid alcohol and stimulants like caffeine and nicotine for at least 2 hours pre-bed, get out of bed and do something if uable to sleep, get up same time each day, comfortable temp, dark and quiet environment, warm drink and snack before bed, daytime exercise) etc.

Yr4 Geriatrics - Lectures Flashcards

(131 cards)