ACH Flashcards
What does NIHSS stand for?
National Institute of Health Stroke Scale
What is the NIHSS used for?
It is used to help a doctor determine the extent of neurological deficit in a patient with a suspected stroke.
How much do you have to score on the NIHSS to be susected of a very severe stroke?
> 25
How much do you have to score on the NIHSS to be suspected of a severe stroke?
15 - 24
How much do you have to score on the NIHSS to be considered to have a moderate stroke?
5 - 14
How much do you have to score on the NIHSS to be considered to have a mild stroke?
1 - 5
How many sections are there in the NIHSS?
11 (but some sections have subsections)
What does Dysarthria mean?
Slurred speech or difficult speaking (because of the muscles)
What percentage of strokes are made by an ischaemic stroke?
85%
What percentage of strokes are made by a haemorrhagic stroke?
10-15%
How many segments is the Middle Cerebral Artery split into?
4 segments (M1 - M4)
What is included in the Inclusion Checklist for Thrombolysis Treatment?
Symptoms of scute stroke
Onset within 4.5 hours
Measurable deficit on NIHSS
Absence of Haemorrhage on CT scan
What does tPA stand for ad what does it do?
Tissue Plasminogen Activator - this activates tissue plasminogen which converts it to plasmin. Plasmin goes on to break down Fibrin clots.
What is the only licensed synthetic tPA for Ischaemic stroke?
Alteplase
What is the risk associated with using Alteplase for thrombolytic treatment of ischaemic stroke?
6% risk of haemorrhage (2-3% of which are considered major/life-threatening)
What is the treatment for someone presenting with an ischaemic stroke, more than 4.5 hours after symptom onset?
Aspirin 300 mg stat dose.
Then Aspirin 300mg OD for 2 weeks, followed by clopidogrel 75mg OD life long
If Clopidogrel is contraindicated in stroke prophylaxis, which drug should be used instead?
Dipyridamole - this is a phosphodiesterase inhibitor
What does TACS stand for in stroke?
Total Anterior Circulation Stroke
What is the criteria for a TACS?
All (3) of the following symptoms:
- unilateral hemiparesis
- homonymous hemianopia/quadrananopia
- higher cortical dysfunction (dysphasia, visuospatial disorder)
What does PACS stand for?
Partial Anterior Circulation Stroke
What is the criteria for a PACS?
Two of the following symptoms:
- unilateral hemiparesis
- homonymous hemianopia/quadrananopia
- higher cortical dysfunction (dysphasia, visuospatial disorder)
What does LACS stand for?
LACunar Stroke
What is the criteria for a LACS?
One of the following symptoms:
- unilateral hemiparesis
- homonymous hemianopia/quadrananopia
- higher cortical dysfunction (dysphasia, visuospatial disorder)
What does POCS stand for?
Posterior Circulation Stroke
What is the criteria for a POCS?
One of the following:
- Cerebellar or brainstem syndrome (DANISH)
- Loss of consciousness
- Isolated homonymous hemianopia
What does DANISH stand for and what is it?
It is a checklist of some of the symptoms that can be seen in cerebellar and brainstem syndrome.
D - Dysdiadochokinesia
A - Ataxia
N - Nystagmus
I - Intention tremor
S - Scanning Dysarthria
H - Heel-shin test positivity (lack of coordination)
Which artery supplies the largest part of the brain?
Middle Cerebral Artery
Which part of the body is more commonly affect in Arterior Cerebral Artery occlusion?
The legs (lower limbs)
What of the body is most commonly affected when there is an occlusion in the Middle Cerebral Artery?
The face
What are some differentials for a TIA?
Syncope
Atypical Seizures
Migraine
Temporal Arteritis
Hypoglycaemia
Labyrinthe disorders (sometime mistaken for POCS TIAs)
What 5 factors are included in Fried’s Phenotype of Frailty?
Grip Strength
Walking Speed
Fatigue
Weight loss
Activity levels
How many steps (Severities) are on the Clinical Frailty Scale?
9 steps, with 9 being terminally ill and 1 being fit and well.
What should be specifically considered in a falls history?
What happened before, during and after the fall?
What is the home environment like? (for rehab purposes and understanding their baseline usually)
PMH - parkinsons, dementia (declining cognition), osteoporosis or osteoarthritis
DH - loads
What is the Acronym for remembering majority of the falls in the elderly population?
DAME
D - Drugs
A - Ageing
M - Medical conditions
E - Environment
What should you think about in the Drugs section of DAME, for causes of falls?
Beta blockers
ACE inhibitors
Diuretics
Sedatives
Opioids
Psychotropics
What should you think about in the Ageing section of DAME, for causes of falls?
Presbyopia
Cognitive decline
Gait changes
Reduced postural sway
Slower reflexes (i.e. putting hands out in front of you when falling)
What should you think about in the Medical Conditions section of DAME, for causes of falls?
Parkinson’s Disease
Osteoporosis
Osteoarthritis
Strokes, Dementia and other neuro conditions
Hypotension, Arrythmias
What should you think about in the Environment section of DAME, for causes of falls?
Walking aids (zimmer frames, walking sticks etc)
Glasses (varifocals)
Home hazards - carpets, stools/ottomans etc
Footwear
What is the most important question to ask when a patiet says they feel dizzy?
“Can you tell me what you mean when you say dizzy?”
What are some of the symptoms that can be seen when a patient says they feel “dizzy”?
Vertigo
Syncope (lightheadedness)
Unsteadiness
Psychogenic dizziness
What are some causes of Vertigo?
Benign Paroxysmal Position Vertigo (BPPV)
Meniere’s Disease
Acoustic Neuroma
Migraine
Cerebellar Stroke
Multiple Sclerosis
What is the diagnostic procedure for BPPV?
Dix-Hallpike Manoeuvre
turn head 45 degrees towards you (on either side), looking at the eyes for any nystagmus. Then drop the head to roughly 30 degrees of the end of couch (still looking for nystagmus).
Do the same on the other side.
Start on the unaffected side.
What is the treatment for BPPV?
Epley Manoeuvre
What is the commest cause for syncopal symptoms?
Postural hypotension
How is postural hypotension investigated?
Using lying and standing blood pressure
Lying for 5 mins - measure bp
Standing - at 1 and 3 mins, measure bp
What are some reasons for a patient to feel unsteady?
Parkinson’s Disease
Osteoporosis
Osteoarthritis
Reduced muscle mass
What are the main investigations of a fall?
FBC
U&Es
TFTs
Folate/B12 - peripheral neuropathy
ECG
Bone profile
Vitamin D
Lying and Standing BP
What is the Tinetti Score?
An assessment of a patients likelihood of falling.
The Tinetti Assessment Tool is a simple, easily administered test that measures a resident’s gait and balance. The test is scored on the resident’s ability to perform specific tasks.
The maximum score for the gait component is 12 points. The maximum score for the balance component is 16 points. The maximum total score is 28 points. The higher the score, the less likely a patient is to have a fall.
Name some types of Gait
Hemiplegic
Ataxic
Parkinsonian
Antalgic
Choreiform
Diplegic
Neuropathic
What tool is used to help determine a patients likelihood of having a fracture?
FRAX tool
What is a DEXA scan?
Scan that is used to assess a patient Bone Mineral Density (BMD)
How frequently are bisphosphonates taken as regular medication?
Weekly
What is the first line Bisphosphonate?
Alendronic acid (Alendronate)
Oral, 70 mg, weekly
If someone is in Vitamin D deficiency and found to have osteoporosis what is their management plan baseline?
Vitamin D supplements (high dose to get them back to normal, for 4 days)
Adcal3 - Vitamin D and Calium supplements as level maintenance
Bisphosphonates - alendronic acid
What is a Colles Fracture?
Radial fracture causing displacement of the radius bone and obvious deformity.
Where are venous ulcers usually located?
Medial ankle
Where are arterial ulcers usually located?
Points of trauma or pressure
What is an Aphthous ulcer?
They are small, shallow lesions that develop on the soft tissues in your mouth or at the base of your gums
What is the 4AT test?
It is a test for delirium - it is the quickest method of assessment
What are the 4 A’s in the 4AT test?
Alertness
AMT4
Attention
Acute course
What does CAM stand for?
Confusion Assessment Method
What is the criteria for the CAM assessment?
To be positive, patient must have features 1 & 2, plus either 3 or 4
The presence of acute confusion, with fluctuation
AND
Inattention (difficulty concentrating)
AND, EITHER
Disorganised thinking
OR
Altered level of consciousness (either heightened arousal/agitation or drowsy)
What are the risk factors for Delirium?
(PINCH ME)
P - Pain
I - Infection
N - Nutrition
C - Constipation
H - Hydration
M - Medication
E - Environment
What are some of the medications that can contribute to delirium?
Anticholinergics
Promethazine
Codeine
Amitryptilline
Diuretics
ACE Inhibitors
Beta Blockers
How do you manage delirium?
Descalation Techniques:
Reassurance, Encourage mobility, Keep familar items around, Promote a normal sleep-wake cycle, Encourage oral intake and fluids
and Sedation if needed
What are some types of laxatives?
Bulk-forming laxatives
Osmotic laxatives
Stimulant laxatives
Faecal softeners
How do bulk forming laxatives work?
And what is one example?
Increases fluid retention within the stool, thus increasing the faecal mass.
ispaghula husk and methylcellulose
How do osmotic laxatives work?
and what is one example?
Increases the amount of ffluid within the large bowel
Macrogols and Lactulose
How do stimulant laxatives work?
and what is one example?
Stimulating peristalsis
Senna, bisacodyl and sodium picosulphate
How do faecal softeners work?
And what is one example?
Increases fluid content of the stool which reduces surface tension (ad makes it easier to excrete)
Glycerol and sodium docusate
What are the 5 pillars of the Mental Capacity Act?
Person must be assumed to have capacity
Use all practicable steps to help the person make the decision
Persons are allowed to make unwise decisions
Decisions must be made in the best interests of the person
Least restrictive option
What is an Essential Tremor?
A tremor that is made worse by carrying out actions such as tryig to carry a cup or reaching for something
What is the triad of symptoms for Parkinson’s?
Resting tremor
Bradykiesia
Rigidity
(postural instability is an additional factor)
What type of gait would you see in Parkinson’s Disease?
Shuffling Gait
What are some differentials of Parkinson’s Disease?
Lewy-body dementia
Drug-induced parkinsons
Vascular Parkinsonism
Multi-systems atrophy
What is the main (principle) treatment of Idiopathic Parkinson’s Disease?
Levodopa or a dopamine agonist
What are some clinical features of Parkinson’s Disease (other than the parkinson’s triad)?
Hypomimia
Hypotonia
Micrographia
Reduced rate of blinking
Reduced arm swing
How is Parkinson’s Disease diagnosed?
By referral to a specialist neurologist - who will make the diagnosis based on knowledge, investigation and deduction.
Which gender is more affected by Parkinson’s?
Men
What are the approved (and researched) medications for Parkinson’s Disease?
Levodopa (synthetic dopamine, which is able to cross the blood-brain barrier)
Dopamine Agonist
Monoamine Oxidase B Inhibitors (MOBI)
What are the main side effects of Levodopa, that make them more risky for treatment?
Increased risk of motor complications (fluctuations, dyskinesias, and dystonia)
There are three types of therapists involved with Parkinson’s Management. Who are they are what is their role?
Physiotherapists
Gait management, rehabilitation of movement ability, helping to achieve functional independence, improving movement initiation
Occupational Therapists
Maintaining personal and work activites, maintaining patients ability to care for self, environmental education, cognitive assessment
Speech and Language Therapists (SALT)
Improving vocal loudness and pitch range
What are some examples of Dopamine Agonists?
Pramipexole, ropinirole, rotigotine and apomorphine
Amantidine
What are some examples of Monoamine Oxidase Inhibitors?
Selegiline and rasagiline
Which part of the basal ganglia is affected in Parkinson’s Disease?
Substantia Nigra
What are the 4 groups of risk factors for Elder Abuse?
Factors relating to the older person
Factors relating to the perpetrator
Relationship between perpetrator and abused
Environmental factors
What factors relating to the abuse person can increase the risk of elder abuse?
Cognitive impairment
Shared living
Functional dependency
Low income
What factors relating to the perpetrator can increase the risk of elder abuse?
Psychiatric illness (including dementia)
Drug and alcohol dependency
Caregiver burden and stress
What relationship factors between the abused and the perpetrator can increase the risk of elder abuse?
Family disharmony
Conflicted relationships
What environmental factors can increase the risk of elder abuse?
Low social support
Shared living
What is a grade 1 pressure ulcer?
Non-blanchable erythema of intact skin. Discoloration, warmth, induration, or hardness of skin may also be used as indicators, particularly in people with darker skin
What is a grade 2 pressure ulcer?
Partial-thickness skin loss, involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion or blister
What is a grade 3 pressure ulcer?
Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
What is a grade 4 pressure ulcer?
Extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss
What is the SSKIN mneumonic for preventing pressure ulcers?
Support surface
Skin inspection
Keep moving
Incontinence checks
Nutrition
