ACH Flashcards
What are the aetiologies of a fall?
DAME:
Drugs
Ageing
Medical records
Enviroment
Medical causes for a fall?
Cateracts
Cardiac arrythmia
Neurological disease - neuropathy parkinsonism, stroke
What differentialsa re there for vertigo?
Peripheral - BBPV, Meniere’s disease, vestribular neuritis, acoustic neuroma
Central - Migraine, brainstem stroke, cerebellar stroke, MS
How is a lying and standing blood pressure done?
- Take baseline BP after 5 mins of lying down
- Take repeat BP at 1 and 3 min since standind up
What is a positive/ abnormal result for a lying-standing BP?
Drop of 20 systolic or 10 diastolic. Also a diastolic of <90 mmHg
What is a a FRAX score?
Predicts 10 year of absolute fracture risk
What is the first line treatment for osteoperosis?
1st line is biphosphonates with Ca/Vit D suplimentation
What are the contraindications to biphsophonates?
- swallowing difficulties
- Barretts oesophagus
- Severe CKD
- hypocalcaemia
What SE are there for biphosphonates?
Indigestion
Heart burn
Stiffness
What would you tell a patient about how to take their biphosphonate?
- Take on empty stomach
- Take with plenty of water
- Remain upright for 30 mins
Patient has a coarse tremor which is worse on movement. Mentions that perants also have the tremor. MLD and treatment?
Essential tremor
Treatment with propanolol or other beta-blockers
An elderly patient has a tremor which is worse at rest and only on one side of body. MLD?
Parkinsonian tremor
What tremors are worse on movement?
Dystonic
Exagerated physiological tremor
Drug induced
Hyperthyroidism
What is an intention tremor and what pathology does it indicate?
Amplitude of tremor becomes worse when reaching end point of deliberate and visual guided movement.
Indicates cerebellar pathology
What signs are there fore cerebellar disease?
DANISH
Dysdiadochokinsia
Ataxia
Nystagmus
Intention tremor
Stuccarto/slurred dysarthria
Hypertonia/ Heel-shin test
What is rigidity?
Velocity independent hypertonia common in parkinons
What is spasticity?
Velocity dependent hypertonia mainly in anti-gravity muscles.
Common in chronic UMNL like MS
What is the triad for lewy body dementia?
Dementia
Parkinsons
Visual hallucinations
What drug can induce parkinsons?
Anti-psychotics
metoclopramide
What is muilti-system atrophy?
Parkinsons with autonomic feature - hypotension, bladder instability
What is athe diagnostic triad for normal pressure hydrocephalus?
Dementia
Gait disorder
Bladder instability
How is normal pressure hydrocephalus diagnosed and treated?
Diagnosis by LP. Treated with VP shunt
What scoring system is used for malnutrition?
MUST score
What is the criteria for thrombolysis in a stroke?
- Symptoms of acute stroke
- Onset within 4.5 hours
- NIHSS scoring
- Absence of heamorraheg on CT
- There is an extensive exclusion criteria
What feature ar ethere of a total anterior circulation stroke?
3 of:
- Unilateral weakness of limb or face
- Homonymous hemianopia
- Higher cerebral dysfunction
What feature are there of a partial anterior circulation stroke?
2 of:
- Unilateral weakness of limb or face
- Homonymous hemianopia
- Higher cerebral dysfunction
What features are there of a posteiror ciculation stroke=?
1 of the following:
- Cerebellar or brainstem syndrome
- Loss of conscioussness
- isolated homonymous hemianopia
What symptoms are thre of a lucunar stroke?
Any 1 of the following:
- Unilateral waekness +/- sensory deficit
- Pure sensory ataxia
- Ataxic hemiparesis
How are patients with delirium treated?
Attempt to orientate patient
De-escelation techniques
Haloperidol or antipsychotic (olanzapine)
What is included in a comprehensive geriatric assessment
Medical diagnosesReview of medsSocial circumstancesAssessment of cognition and moodFunctional abilityEnvironmental assessment
Fried’s phenotype of frailty
Grip strength Activity levelsWeight lossFatigue Walking speed Frailty is associated with death, institutionalisation, adverse outcomes and falls
Falls history
Before the fall- what were they doing, what was the time of day, symptoms before the fall, why do they think they fellDuring- LOC, bite tongue, incontience, injured themselves After the fall- how did they get help, could they get up, complications such as long lie, fracture, head injury Vision, cognition, other PMH, osteoporotic risk factorsDAME! Drugs, ageing, medical conditions, environment
Drug causes of falls
PolypharmacyAnti hypertensivesSedativesOpioidsPsychotropicsGlicliazide- hypoglycaemia
Age related causes of falls
Vision changes Cognitive declineGait abnormalitiesOsteoarthritis Postural instability Sarcopenia Reduction in baroreceptor sensitivity
Medical causes
Cardiac - hypotension, arrhythmiaNeuro disease eg Parkinson’s, stroke, neuropathy Cataracts
Environmental causes of fall
Walking aidsInappropriate footwear Carpets Home hazards
What is vertigo
Sensation of room spinning. Causes include BPPV, Menieres disease, vestibular neuritis, acoustic neuroma Central causes migraine, brain stem ischaemia, cerebellum stroke, MS
Short spells of vertigo (up to one minute), settles spontaneously, occurs on movement of head eg in and out of bed or looking up or turning quickly
Diagnosis BPPVDiagnosed by Dix Hallpike manoeuvre Treat with Epley
Patient feels lightheaded, associated with pallor, sweating, often when pt is standing
Pre syncopal.Suggest a cerebral hypoperfusion due to hypotension. Often postural hypotension Do lying and standing BP. Check meds
Examine patient presenting with dizziness
NeuroEye sightBPCardio resp- pulse, JVP, heart sounds, peripheral oedema, chest soundsMSK- examine hands, hip exam, knee exam, ankle, gait
Tests after a fall
FBCTFTs, B12HbA1cBone profile Urea and electrolytesECG- arrhythmiaCK- only if there way long lie and query rhabdomyolysisUrine dip if urinary symptoms CT brain if head injury and LOC, anti coag use or neuro deficitEcho is HF symptoms Tilt table only if syncope CXR if chest symptoms
Assess osteoporosis risk
FRAX tool. Assesses ten year fracture risk.
First line osteoporosis treatment
Bisphosphonates, calcium, vit D supplements Alendronic acid 70mg weekly.
Confusion assessment tools
AMTS10 quick cognitive assessmentAddenbrookes - dementia toolMOCA good sensitivity but time consuming MMSE
Things that can lead to confusion
Change in environmentSubdural haematoma or intracranial bleedsHip fractureConstipation!PainLow BPDehydration Previous delirium Recent surgery Poor sleepAny infection
Tests and tools assessing confusion and delirium
Confusion assessment method (acute onset, fluctuating course, imattention, disorganised thoughts, altered consciousness)4AT- alterness, attention, acute, AMT4
Things to review if patient delirious
FNCUEreview for sepsis- do obsFluid intake Constipation MSU ECGCXRcalcium Blood cultures if think sepsis
How to treat delirium
Identify and manage underlying cause Ensure effective communication De-escalate if distressed- use familiar staff or family. Do not moveConsider short term haloperidol or olanzapine if patient is at risk or risk of hurting others Ask about alcohol intake
Prognosis of delirium
Two thirds recover (1/3 quickly, 1/3 slowly)One third do not recover completely It is associated with with numerous negative outcomes- longer hospital stays, increased incidence of dementia, increased complications such as falls and pressure ulcers, increased rate of admission to long term care, more likely to die
Prevention of delirium
Good lighting, clear signage, reorientation, reduce chance of dehydration and constipation, hypoxia, try to make person mobile ASAP, infection, meds review, assess pain, ensure good nutrition, heating and visual aids, try encourage good sleep
Steps of a medication review
Identify objectives of drug therapyIdentify which drugs are essential Does the patient have any unnecessary drugsAre all objectives being achievedAre there any ADR or at risks ADRsDrug cost effective Is the patient taking the meds
What are the features of Parkinsonism
Bradykinesia- slowness of initiating voluntary movements. Difficulty in sustaining repetitive movements Rigidity - involuntary increase in muscle tone. Present through range of movement Tremor- rhythmic involuntary movements eg pill rollingPostural instability
Causes of parkinonism
Idiopathic Drug induced- cyclizine, haloperidol, prochlorperazine, metoclopramideVascular Parkinson’s - small strokes in basal ganglia
Features of drug induced Parkinsonism
Usually symmetrical onset Treatment- stop or reduce meds. Liase with psych
Features of vascular Parkinsonism
Extreme shuffling gait but preserved arm swing Tremor less common Approx 50% levodopa
Features of idiopathic Parkinson’s
Gradual onsetUnilateral initially and one side always worseUnilateral and fine tremorHypophoniaMicrographiaFreezing gait Treatment- levodopa or dopamine agonist and physical activity and therapy
Essential tremor
On action SymmetricalAlcohol improves itFHCoarse tremorJaw tremorLeg tremorNo evidence of bradykinesia or gait disturbance Non specific beta blockers eg propanolol can be effective in reducing tremor
Scans done to determine whether essential tremor or PD
DAT scan can show decreased dopamine uptake Not often indicated unless trouble distinguishing between essential tremor and PD
Tremor worse on movement
Essential tremorDystonic tremorExaggerated physiological tremorHyperthyroidism Dystonic tremors
Intention tremor
Cerebellum disorders.
Dementia with Lewy Bodies
Triad of dementia, Parkinsonism, visual hallucinations Fluctuations in alertness Shared care with psychiatry, neurology and geriatrics
Progressive supranuclear palsy
Early falls, truncate rigidity, vertical gaze palsy Reduction in midbrain volume on MRIRequires early speech and language review
Normal pressure hydrocephalus
Triad of dementia, gait disorder and bladder instability Diagnostic lumbar puncture and CSF removal then ventriculoperitoneal shunt
Three steps to diagnosing Parkinson’s disease
1- diagnosis of a parkinsonian syndrome 2- exclusion criteria3- supporting evidence eg unilateral tenor, preofessige, persistent asymmetry, good response to levodopa If wanting second opinion, do not try levodopa as this could mask symptoms
Treatment of Parkinson’s disease
Co beneldopaLevodopa with benserazide which acts as a dopa decarboylase inhviitor so stops the additional creation of dopamine outside of the brain therefore more dopamine for the brain and less systemic side effects eg nausea Second line is dopamine agonist. These are not desirable as can cause hallucinations and behavioural problems eg gambling, overeating, hyper sexuality
What is the MUST score
Malnutrition universal screening toolFive step screening tool to identify adults who are malnourished, at risk of malnutrition or are obese1. Measure height and weight to get BMI2. Note percentage unplanned weight loss and score using tables3. Establish acute disease effect and score4. Add scores from steps 1- 3 to obtain risk of malnutrition 5. Use management guidelines and or local policy to develop care plan
Grading of ulcers
1 non blanchable erythema. Skin intact2. Partial thickness loss- abrasion or clear blister3. Full thickness skin loss. Sub cut fat may be visible4. Muscle or bone or tendons exposed
How to prevent pressure ulcers
SKINS support surface needs to be adequateKeep or movingIncontinence (manage) Nutrition and hydration Skin inspection to Detect early signs
How to identify stroke, in community and in A&E
Community - FASTA&E- Rosier score
If stroke suspected, what should you do
CT ASAP to look fo signs of haemorrhage. CT angiography can also help. Take full history Thrombolysis alteplase if under 4.5 hours
Thrombolysis check list
Symptoms of acute strokeOnset in last 4.5 hours Measurable deficit on NIHSSAbsence of haemorrhage on scan
Follow up after thrombolysis
CT scan after 24 hours to check that there has been no haemorrhage following thrombolysis Do NIHSS again to see if there is an improvement Refer to physio and OT
Unilateral weakness of face, arm and legHomonymous hemianopiaHigher cerebral dysfunction - dysphasia
Total anterior circulation stroke
Two of :unilateral weakness of face, arm legHomonymous hemianopia Higher cerebral dysfunction
Partial anterior circulation syndrome
One of:Unilateral weakness of face, arm legPure sensory strokeAtaxic hemiparesis And no evidence of higher cerebral dysfunction
Lacunae syndrome
One of Cerebellum or brainstem syndromesLoss of consciousnessIsolated homonymous hemianopia
Posterior circulation syndrome
Risk factors for haemorrhagic stroke
HypertensionCerebral amyloid angiopathyAneurysms eg with poly cystic kidney diseaseCerebral arteriovenous malformationsBrain tumours
If TIA, what tool should be used to assess stroke risk
ABCD2Age over 60Blood pressure >140/90Clinical features max 2 points (2 for unilateral weakness, 1 speech difficulty)Duration (2 for over 60, 1 for 10-59, 0 for less than 10)Diabetes 1Max 7 points 4 or Above is high risk of stroke
Following TIA, what makes a stroke highly likely
ABCD2 score of over 4 AF Multiple TIAs
DVLA And TIA
If normal driverStop driving immediately No driving for four weeksNo need to inform DVLA
DVLA and stroke
No driving for four weeks and must tell DVLA. after the four weeks, need reassessing
Differential for TIA
SyncopeAtypical seizureMigraineTemporal arteritis Retinal haemorrhage or detachmentHypoglycaemiaLabyrinthine disorders
Test ps after TIA diagnosis
ECG to check for AFcarotid Doppler, do carotid endarterectomy is over 70% occluded leading to symptomsFBC, UE, LFT, lipids, blood glucose, BMI
If AF present with TIA..
Do CHADS2VASC and HASBLED to assess clot and bleeding risk
Headache, weakness in left side developed over 30 mins. Drowsy. FAST positive
Likely to be a haemorrhage. Still get CT
Risk factors for stroke
a HTN, peripheral vascular disease, ischaemia heart disease, smoking, diabetes , AF, combined pill, clotting disorders, vasculitis, carotid stenosis
