Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

AGEING & CO MPLEX HEALTH RE VISION M A R K M I T R A & A M Y S H A W ( 5 T H Y E A R M E D I C A L S T U D E N T S )OVERVIE W OF SE SSI ON • Geriatric giants & comprehensive geriatric assessment • Brief summary of presentations/conditions • Prescribing in ageing and complex health • Worked case(s)CON DI TI ONS I N AGE IN G A ND HE ALTH C overed in this block: Covered in other blocks • Delirium • Arterial ulcers • Essential tremor • Atrophic vaginitis • Malnutrition • Benign paroxysmal positional vertigo • Osteoporosis • Venous ulcers • Parkinson’s disease • Pressure sores • Stress incontinence • Stroke • Transient ischaemic attack • Urinary incontinence 1 / 8 / 2 0 2 5 3GE RI ATRI C GI ANT S Instability Immobility Incontinence Impaired cognition IatrogenesisG E R I AT R IC A SS E SS M E N T TO OL • Holistic assessment of a geriatric patient to assess health & wellbeing, to ensure needs of patient are met • Any health care member can perform this assessment Key considerations: a. Physical assessment b. Functional, social and environmental assessment c. Psychological components d. Medication review 1 / 8 / 2 0 2 5MA LNUTRI TI ON • Complex & multifactorial Criteria: • BMI <18.5 • Unintentional weight loss of 10% in previous 3-6months • BMI <20 with unintentional weight loss of 5% in previous 3-6months Screening tool: MUST (Malnutrition Universal ScreeningTool) 1 / 8 / 2 0 2 5NUTRI TI ON ASSESSMEN T • Use the MUST tool to identify patients at risk of malnutrition • If high risk (>2) requires assessment by dieticianFA LL S Pre-fall Post-fall • Scene, Collapse or fall? • Injury • Neurology/Cardiology red flags • Aura • Recurrent falls • Eyesight • Environment and screen for prior illness Fall Social hx • Mechanism • LoC • WitnessFA LL S RI SK FACTO RS • History of falls • Conditions affecting mobility/balance (arthritis, diabetes, incontinence, stroke, syncope, or Parkinson's disease) • Other conditions; muscle weakness,poor balance,visual impairment, cognitive impairment,depression,and alcohol misuse. • Polypharmacy and specific drugs (e.g. sedation, postural hypotension, diuretics, anticholinergic burden) • Environmental hazardsA C B CA LC UL ATO R https://www.acbcalc.com/ • Medication review • Identify medication with high ACB • Consider altering dose/stopping medication 1 / 8 / 2 0 2 5FA LL S MAN AGE MEN T Investigation: • Neuro/cardio exam • Bloods (FBC,U&Es,bone profile, CRP) • ECG, LSBP Management: • Address risk factors/precipitating factors • Refer to falls clinic • Med review • Strength/ balance training This is not a 100% Set pathway, and there is a lot BONE HEALTH of leeway for clinician discretion. Screening: Treat: • Hip fractures in older adults Generally anyone with • A postmenopausal woman, or a man age ≥50 •Current or frequent use of oral has a symptomatic osteoporotic vertebral Female 65+yrs old corticosteroids. Male 75+yrs old •A previous fragility fracture. fracture or treated with glucocorticoids (>3months) • Generally, if someone has a fragility fracture, they are almost certain to be prescribed Risk assessment with: bisphosphonates FRAX (40-90yrs) or QFracture (30- 84yrs) Consider treating lifestyle factors: • Stop smoking, reduce alcohol If medium or high risk • Diet: Vitamin D and Ca • Healthy weight and exercise Osteopenia T score of -1.0 to -2.5 DEXA Osteoporosis Tscore of < -2.5 1 / 8 / 2 0 2 5BI SPHOSPHONAT ES COUNSEL LI NG Action: prevent thinning of the bones Timing: Takes6 months to have effects, effects not felt. How to take: take one tablet at the same time each week.Tablet should be taken with a large glass of water in the morning, 30mins before food. Patient should remain sitting upright for 30mins after taking tablet to reduce GI SEs. If patient forgets tablet, they should take it as soon as they remember – do not take 2 tablets in one day. Length of time: taken for 5 years, then check DEXA results. Effects: takes 6 monthsuntil you feel effectsof bisphosphonate working. Tests: review by dentist prior to starting bisphosphonates. Check bone profile, vitamin D, PTH, renal functions.Repeat DEXA every 2-5yrs Important side effects: common; oesophageal irritation, abdominal pain, nausea, GI upset, joint/muscle pain. Rare; osteonecrosis of the jaw, atypical femur fracture Contraindications: Abnormalities of oesophagus (e.g.achalasia, strictures); hypocalcaemia Supplementary information: lifestyle advice – exercise and diet 1 / 8 / 2 0 2 53CO N F U SI O N Common presentation in geriatric patients Many factors: oInfection oConstipation oMalnutrition oHypoglycaemia oMedication 1 / 8 / 2 0 2 5D EL ERI UM • Disorder in which patients exhibit confused thinking & lack of awareness • Common develops quickly over hours – days • Most patients return to baseline after underlying cause treated (however not always the case) • Beneficial to gain co-lateral history to identify likely cause & baseline for patient 1 / 8 / 2 0 2 5SCR EE NI NG FO R D EL ERI UM • Most importantly – HISTORY/CO-LATERAL HISTORY Identify cause: • Urinalysis • Liver function tests • Sputum culture • Inflammatory markers • Full blood count • Drug levels *OUCH!!! • Folate and B12 • Thyroid function tests • Urea and electrolytes • Chest X-ray • HbA1c • Electrocardiogram • Calcium 1 / 8 / 2 0 2 54 AT • Rapid assessment test for delirium Results: • 4+: possible delirium +/- cognitive impairment • 1-3: cognitive impairment • 0: delirium/severe cognitive impairment unlikely 1 / 8 / 2 0 2 5M A N AG E M E N T 1st line: Ensure effective communication and reorientation 2nd line: haloperidol,lorazepam (parkinsons) P RE V E N T Address: • Environment • Hydration/constipation • Immobility • Pain • Sleep • Nutrition 1 / 8 / 2 0 2 58ME MORY LO SS Hx: • Collateral Hx Differentials: • Dementia: • Baseline • Sx • Alzheimers (50–75%) • Risk assessment • Vascular (up to 20%) • Fronto-temporal (2%) • Lewy-body (10–15%) Cognitive assessment tools: • Depression/anxiety/Psychosis • 10-CS • 6CIT • NPH • MIS • Alcohol,Vitamin deficiency • Mini Cog • Drugs • Mild cognitive impairment (MCI) 1 / 8 / 2 0 2 5MCA , D OLS Principles of MCA 2005: Capacity principles: • Understanding •Presumption of capacity •Support to make a decision: A • Retain person should not be deemed • Reason to lack capacity unless all practical steps have been taken • Communicate to help them make a decision. • A person has the right to You can only be deprivedofyour liberty make an unwise decision. where (1) it is shown to be in •Any decision must be in their your‘best interests’ to protect youfrom best interests. harm,(2) a proportionate response to the likelihood andseriousness ofthat • Least restrictive option alternative available.less restrictive 1 / 8 / 2 0 2 5M OV E M E N T D I SO RD E R S • Results in abnormal bodily movements • May be reduced/increased movement • Voluntary/involuntary movement 1 / 8 / 2 0 2 5PAR KI NSONS D ISE ASE • Loss of dopaminergic neurones in basal ganglia (Irreversible) • Clinical diagnosis Unilateral gradual onset symptoms vs bilateral rapid to differentiate Symptoms: medication induced Parkinsonism TRAP Complications : - Motor; "on-off" fluctuations • Tremor - Non motor complications • Rigidity • Akinesia/Bradykinesia • Postural instability 1 / 8 / 2 0 2 5L EVO DOPA • Usually combined with decarboxylase inhibitor (carbidopa or beserazide) • Quick onset, generally provides good control for 4-6 years, most effective option • Time sensitive medication Side effects • Impulse control disorders • Dyskinesia • Common side effects (e.g. dry mouth, anorexia, palpitations, postural hypotension, psychosis, sleepiness) Alternatives generally 2nd line: dopamine agonist (bromocriptine), MAOi (selegelline) 1 / 8 / 2 0 2 5PAR KI NSON PLUS SYND ROME S • Progressive supranuclear palsy o Vertical gaze dysfunction, dysarthria, commonly aged 50-60s • Multiple systems atrophy o Rapid, early profound autonomic dysfunction (postural hypotension, urogenital dysfunction), poor response to treatment • Dementia with Lewy bodies • Corticobasal degeneration 1 / 8 / 2 0 2 5E SSEN TI AL T REMO R • Fine symmetrical tremor (6-12 Hz) • Worse on voluntary movement • Medication management involves either Propranolol or primidone • Progressive disease - symptoms will worsen over time 1 / 8 / 2 0 2 5STRO KE Suspect stroke if sudden unexplained focal neurological deficit Features of stroke vary and can FAST screening tool include: • Confusion/altered Hx: consciousness • Headache • Time of onset is essential • Unilateral weakness/paralysis • Good review of systems • Sensory loss • Ataxia • Atherosclerosis and bleeding risk • Dysphasia, dysarthria factors important • Visual disturbance • Photophobia • Dizziness/vertigo/loss of balance 1 / 8 / 2 0 2 5 STRO KE MAN AGE ME NT Investigations: ECG, blood glucose, bloods, NEWS, non-contrast CT-Head Ischemic stroke: Hemorrhagic stroke: Aspirin 300mg Anticoagulant reversal (e.g. vitK, DOAC reversals ) Thrombolysis - if within 4.5hrs A to E - if within 9hrs and signs of salvageable brain tissue Nimodipine 60mg for SAH Consider thrombectomy - If within 6 hrs Referal to neurosurgery - If within 24 hrs and salvageable brain tissue 1 / 8 / 2 0 2 5STRO KE : SECO NDA RY PRE VEN TIO N Statin 80 mg within 48hrs Antiplatelet therapy: - Consider dual antiplatelet therapy (Aspirin 75mg plus Clopidogrel 75mg) for 14 days if low-risk of bleeding - If high-risk then Aspirin 75mg alone for 14 days. - On day 14 stop all other antiplatelets and start clopidogrel 75mg OD lifelong Optimise other health conditions (e.g.HTN, diabetes , HF) 1 / 8 / 2 0 2 5TI A Symptoms do not exceed 24hours. Referral to rapid accessTIAclinic within 24 hours If there has been more than 1 TIA (crescendo), then consider admission Carotid doppler - If stenosis is more than 70% (according to ECST),then consider carotid endarterectomy 1 / 8 / 2 0 2 5ST R OK E M I M I C S • Toxic/metabolic disturbance (hypoglycemia, hyponatremia, drug/alcohol toxicity,Wernicke's encephalopathy) • Conditions which can cause dizziness or disturbed balance (e.g.syncope, vertigo, Meniere's, labyrinthitis) • Neurological (seizures, migraine with aura,MS, neuropathies, Bells palsy) • Trauma • Tumours • Infection/inflammation (sepsis, CNS abscess, meningitis/encephalitis, GCA) 1 / 8 / 2 0 2 5L IFE AFT ER STROK E Needs MDT and holistic treatment: Prognosis: Stoke is 4th leading cause of mortality - SALT (swallow assessment), nutrition assessment,PT, OT, in UK social worker, stroke coordinator - Stoke unit Mortality; 1 in 7 patients with acute stroke die DVLA Disability; 40% will have • Cars and motorcycles: difficulty with basic ADLs 6 o stop driving for 1 month if stroke. InformDVLA if months following their stroke ongoing symptoms after 1 month. o Stop driving if TIA untilTIA is confirmed.Then stop driving 1 month, do not need to inform DVLA • Larger vehicles (e.g.buses, lorries): stop driving,inform the DVLAif patient had stroke or TIA 1 / 8 / 2 0 2 5 Red flags: U R I N A R Y I N C O N T I N E N C E - Back pain - Hematuria Stress Urge Overflow Weak/damaged pelvic floor Overactive bladder Risk factors: Risk factors: Incomplete emptying due to • Multiparity either: • BPH/prostate cancer • Related to labour – perineal tear, episiotomy, surgery, • Autonomic neuropathy • Bladder outlet obstruction • Infection (UTIs), constipation • Detrusor underactivity Management: Management: Management: Lifestyle, pelvic floor exercises (min. 8 contractions performed Lifestyle, bladder retraining, medical Refer to urologists or 3 times/day for 3 months), management (oxybutynin, urogynecology medical management mirabegron), May need catheterization (duloxetine), Surgery 1 / 8 / 2 0 2 5M E D RE VI E W START/STOPP tool for reviewing medications Palliative care medications (Palliative care section in BNF) Anticipatory meds: • Nausea: Levomepromazine • Pain: morphine (opioid) • Secretions: Hyoscine butylbromide or glycoperronium • Agitation/irritation: Levomepromazine or haloperidol Deprescribing – symptom control & personalised management Common drugs to stop in palliative care: • Statins, antiplatelets, ACEi, beta-blockers 1 / 8 / 2 0 2 5 33E X PL A IN D N AC P R Need an understanding of patient Hx and ICE Explain DNACPR in clear terms - For in hospital cardiac arrests (UK),<20% of patients survive hospital discharge - Explain why it is appropriate for the patient to consider DNACPR is a part of advanced care planning – ReSPECT form DNACPR is a medical decision Offer leaflet/website 1 / 8 / 2 0 2 54CASE STUDY (1) • Mrs Edwards is a 84-year-old female brought to A&E by her daughter. • Daughter reports over the past 2 days Mrs Edwards has become confused & agitated. • PMH: HTN,T2DM, osteoporosis • MH: metformin 500mg BD, ramipril 5mg OD, calcium & vit d supplements, alendronate 70mg once weekly 1 / 8 / 2 0 2 5CASE STUDY (1) • O/E: o BP 135/85mmHg o HR 88bpm o RR 20 o Temperature 37.8C o SpO2 97% on room air o Abdominal examination: mild suprapubic tenderness What is your differential diagnosis? What further investigations would you request? 1 / 8 / 2 0 2 5CASE STUDY (1) • Differential diagnosis: o Delerium(secondary to infection, metabolic imbalance, ormedication) o Dementia with acute exacerbation Diagnosis: delirium secondary to UTI. o Depression Hyponatraemia aiding confusion. o Intracranial event (e.g. stroke, subdural haematoma) • Investigation: o FBC (Hb 105, WCC 13.2) o U&E (Na 128, K4.1, Creatinine 95) o CRP (78) o LFT o Glucose o Calcium How would you manage the o TFT delirium? o Urinalysis (+++ leucocytes, ++ nitrites) o Chest X-ray 1 / 8 / 2 0 2 537MA NAGE ME NT OF D EL ERI UM • Conservative: o Reorientation strategies o Minimize noise o Hydration & nutritional support • Medical: o IV antibiotics o Correct hyponatraemia o Low dose haloperidol/lorazepam On review, Mrs Edwards daughter mentions she fell in the bathroom the day before the confusion started.What further investigations need to be considered at this stage? 1 / 8 / 2 0 2 5I N V E S T I G AT I O N S How would you modify her osteoporosis management & prevent future falls? • Imaging: X-ray hips/pelvis • DEXA scan • Fall risk assessment • Medication review 1 / 8 / 2 0 2 5O S T E O P O R O S I S M A N A G E M E N T • Optimise calcium & vit D • Consider zoledronic acid & denosumab if compliance with oral alendronic acid poor • Falls prevention programme • OT home safety evaluation Key points: • Delerium in older adults is often multifactorial • Optimise bone health to reduce fracture risk • Medication review if presentation confusion/falls • Holistic management in geriatrics is key 1 / 8 / 2 0 2 540C A S E S T U D Y ( 2 ) • Mr Jones is a 76- year-old male brought to his GP by his wife. • Mr Jones reports a 6-month history of difficulty walking, shuffling gait and frequent falls. • Recently, he has experienced urinary urgency & leakage. • PMH: HTN,T2DM,TIA 2 years ago. • MH: amlodipine 5mg OD, metformin 1g BD,clopidogrel 75mg OD. 1 / 8 / 2 0 2 5C A S E S T U D Y ( 2 ) • O/E: o Gait: slow, shuffling steps, reduced arm swing o Postural instability: positive pull test o Tremor: resting tremor noted in right hand o Bradykinesia o Urinalysis (--- leucocytes/nitrites/protein/blood) o Bladder scan: post-void residual volume of 120ml What is your differential diagnosis? 1 / 8 / 2 0 2 5C A S E S T U D Y ( 2 ) • Differential diagnosis: o Parkinson's disease o Normal pressure hydrocephalus o Vascular parkinsonism o Multisystem atrophy (MSA) What investigations should be performed? 1 / 8 / 2 0 2 5 C A S E S T U D Y ( 2 ) • Bloods: FBC,U&E, LFT, glucose,TFT, calcium, B12/folate • Imaging: MRI brain • Urodynamic study for bladder dysfunction MRI findings: diffuse white matter changes consistent with vascular pathology. No evidence of hydrocephalus or masses. Diagnosis: vascular parkinsonism. 1 / 8 / 2 0 2 5M A N A G E M E N T Motor symptoms: Urinary symptoms: • Levodopa/carbidopa • Trial of bladder retraining • Physiotherapy • Consider anticholinergic • Occupational therapy medication • Consider intermittent catheterisation 1 / 8 / 2 0 2 5L O N G T E R M M A N A G E M E N T & P L A N N I N G Optimization of CV health: • Clopidogrel 75mg OD • Monitor BP • Encourage dietary/lifestyle changes Long term planning: • Support groups • Palliative care if symptoms worsen • Advance care planning *& LPA 1 / 8 / 2 0 2 5SUM MARY • Falls (incl. Hx risk factors) • Brief Geriatric 5Ms, GCA and Nutrition • Confusion (delirium and MCADoLs) • Memory loss (Hx, testing tool, brief types of dementia) • Movement disorders (Parkinsons, MSA, PSP,medication) • Bone health (osteoporosis FRAX and ortho-geriatrics) • Stroke and TIA • Palliative Prescription review (STOP/START tool) • DVLA 1 / 8 / 2 0 2 5THA NKS FO R L ISTE NI NG Many thanks to PPALs for organising this session. References: • Pulsenotes • NICE CKS • Focused History taking OSCE textbook • Passmedicine • Age UK • MIND • NOGG 1 / 8 / 2 0 2 5