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Geriatrics (Instability (Fractures (NOF) (On Discharge (Day 3: Have…

- - - - Examination
        
        Gait, Rhomberg's, MSK, Balance ( Vestibular - hallpikes)
        
        Full Neuro ( Including Vibration and proprioception)
        
        Feet and footwear
        
        MMSE
        
        Lying/Standing BP's
        
        CVS Exam
      - Investigations
        
        B12, Folate, TFT's, FBC, U&E's, Glucose, CA, PTH, ALP, Vit D
        
        ECG
        
        BMD, Echo, Holter, CT Head if indicated
      - History
        Hx of falls ( No, Cirumstances)
        
        Medications (Benzo's; BP lowering, Parkinson's)
        
        Acute and Chronic Medical Problems
        
        Gait - Mobility problems, exercise tolerance
        
        Osteoporosis/# Hx
        
        RF
        
        Driving Safety
    - - MULTIDISCIPLINARY
        
        Medication Review
        
        Tx: Posural hypotension
        
        Opthal review, bifocal avoidance
        
        Vit D and Ca Supplamentation ( vit D <50)
        
        Osteoporosis Tx
        
        Physio - Balance, gait and walking aid presciption
        
        OT Home visit and home modifications
        
        Falls education Groups
        
        Footwear Review
        
        Consider: Social Work for ACAT, Podiatry, Continence Nurse
  - - - *(L-Dopa effect reduces or too much L-Dopa)
        S/S: Motor fluctuation, N/V Posthypotension, Freezing/Falls, Cogitive inpairment, REM sleep disorder, Anosmia
    - - Mainstay: Levodopa and Carbidopa ) Sinemet or Mardopa (50 +12.5mg TDS → 100+25mg over 1-2 weeks
      - Anti-Cholinergics: Bonstrapine ( Arkine, Akineton)
      - DA rec agonists: Pramipixole or Bromocriptine
      - COMT inhibitors: Entacopone
      - MOA-B: Selegaline
      - SE: N/V, Postural Hypotension, Confusion, muscle spasms
    - - Progressive neuro-degeneration of DA Neurons in Substantia Nigra
        
        Classic S/S: Bradykinesia, Resting Tremor, Cogwheel Rigidity
        
        Other S/S: Postural instability, Slow, Shuffling, Stooped gait, Autonomic Dysfunction ( Hypotension, Constipation, Urinary Issues, Drooling, Dysphagia, Mask like facies)
  - - - Intra- capsular classification - GARDEN CRITERIA
    - - ongoing Pain managment
        
        Paracetomol 1g QID
        
        NSAIDS 200mg-400mg
        
        Tapentadol 50mg BD
        
        Targin (Oxycodone and Naloxone) 2.5/5mg BD
        
        Movicol 2 sachets BD
        
        Breakthrough pain: Oxycodone 5-10mg PRN 2 hrly
        
        Ondansatron 4mg QID
        
        Metaclopramide 10mg TDS total 40mg
        
        Extratrochanteric Dynamic Hip screw
        
        Intratrochanteric: ORIF(Depednign of displacement) OR Hemi-arthroplasty( Head and Neck replacement)
    - - Day 3: Have someone to help get in and out of bed, and physio everyday till home
      - Day 1 post-op: Get out of bed ( Give pain relief, use walking frame for weight distribution through the arms)
      - Issue: Arthritis in shoulders and hands; Anyone that says that they have a high pain threshold, Dementia
- - - - Causes: DIAPERS
        Delirium
        Infection
        Atrophic Vaginitis (women)
        Pharmacological Causes
        Psychological Causes eg. Abulia
        Excess urine
        Restricted Mobility
        Stool impaction
    - - Investigations
        Urinalysis: Screen for Haematuria, UTI, Malignancy
        Urodynamics
      - Types
        
        Mixed Incontinence
        
        Combo of stress and urge
        
        Stress Incontinence
        
        Involuntary leakage on effort due increased intra abdominal pressure
        
        Straining. laughing, coughing, sneezing
        
        Urinary Retention
        
        Due to: Outflow obstruction or Atonic/a-contractile Bladder
        
        Urge Incontinence
        
        Involuntary leaked accompanied/preceded by urgency
      - Risk factors
        
        ↑ Age
        
        Obesity
        
        LUTS
        
        Residential Care
        
        Constipation/Faecal impaction
        
        Prolapse
        
        Stroke
        
        Parkinson's
        
        MS
        
        Diuretics
        
        Caffeine Use
  - - - Oxybutinin/ Oxtrol
        Anticholinergic - Ms Rec on detrusor muscle → relaxation
        
        Systemic SE: Dry mouth, dry eyes, urinary retention, Constipation
        
        Dose: 2.5mg daily OD or BD to max 20mg
        
        PBS
      - Solifenacin and darifenacin/ VESICARE
        
        Newer
        
        Selective M3 rec
        
        Slightly more effective the Oxybutinin
        
        SE: Anticolinergic
        
        Not PBS
      - Mirbegron ( Betmiga)
        
        Urge Incontinence
        
        Beta3-adrenoreceptor agonist; relaxes bladder muscle during the storage phase → increasing bladder capacity.
        
        SE: HTN, Nasopharyngitis, UTI. Don't use:eGFR >30
        Dose: Start 25mg, Up to 50mg
      - Treatment of BPH
        
        Dutasteride (Avodart/Duodart): 5‑alpha-reductase inhibition - ↓Prostate size
        
        Flomaxtra
        * SE: impotence, decreased libido, ejaculation disorder
    - - Bulk-forming Agents: Psyllium ( Metamucil), Action in: 12-72hrs, Bulk stool by absorbing water and ↑ faecal mass
        
        Surfactants(Softeners): Docusate, action in: 24-72hrs, 100mg BD, ↓er surface tension of stool, allowing Absorption of water
        
        Osmotic Agents: Lactulose (24-48hrs), Glycerine( 15-60mins), Intestinal water secretion, increasing stool frequency, SE: Electrolyte Disturbance, Bloating, Flatulence
        
        Stimulants: Bisacodyl (Dulcolax); Senna (Senokot) Action 6-12hrs; Alters Electrolyte transport by intestinal mucosa and increase intestinal motility
- - - - Will: Legal document detailing what a person would like to do with their estate upon death. Also names the Executor.
        
        If person dies without a will - Dies intestate. Estate divided bw Surviving spouse and children.
      - General Non-Enduring Power of Attorney: Attorney appointed to make financial decisions in behalf of a person for limited period of time.
        Enduring Power of attorney: Principal apppoints attorney to make decsionsin the future. Remains valid of person loses capacity.
        
        Person makes decisons until they lose capacity.
        
        Person nominates the matters that the attorney can make decisions on.
      - Enduring Power of Attorney (Medical Treatment
        
        Another person is appointed to make decision regarding medical treatment including both consent nad refusal of treatment.
        
        Only valid when person loses capacity.
        
        Cant make decisions regarding reproductive procedures or organ transplantation
        
        EPOA (Med treatment) has precedence over EPOA.
        
        Distinct from EPOA with healthcare powers: They can consent to treatment, but cannot refuse treatment.
    - - Loss of Capacity disqualifies from:
        
        Voting
        
        Entering into binding contracts
        
        Having sexual relations with another person
        
        Authorising many forms of medical treatment
      - Assessing
        
        Valid trigger for assessment
        
        Informe patient about the assessment and involve them
        
        Adequate information gathering: Issue, optionsm choices and consequence. Collateral Hx incl.
        
        Advising and educating patient regarding the above
        
        Assessing the patient's capacity
        
        Taking appropriate action based outcome
        
        Jane Courtney Tute:
        
        Get patient to explain what you have said back to you in plain language.
- - - - MMSE: Memory<24/30
        
        30/30: Doesnt exclude Cognitive Impairment
      - MOCA: Fronto-temporal Functioning
    - - PHARMOCOLOGICAL: Acetylcholinesterase Inhibitors
        
        Donepezil: Aricept
        
        Rivastigmine: Exelon, Rivastigmelon
        
        Galantamine (Reninyl)
        SE: N/V, vivid dreams, depression, Fatigue, Bradycardia
      - PSYCOSOCIAL
        
        Exclude Delirium. Pain Depression, Anxiety
        
        Identify precipitances, Time of day, Hunger,Tiredness, Pain, ADL's Environment Loneliness
        
        Interdisciplinary Collaboration
        
        Carer education
        Counselling for Carers and Family
        
        Respite Care
        
        Exercise, Social Activities, Memory aids
        
        Support Groups: Dementia WA
        
        Avoid Conflict: Do not argue with the patient. Distract or offer a pleasant alternative