Ageing and Complex Health Flashcards
What tool can be used to estimate risk of fractures
FRAX tool - estimates 10 year fracture risk and guides whether or not to initiate treatment
Treatment for osteoporosis
Bisphosphonate - Alendronic acid 70mg once weekly
Calcium and Vitamin D supplements
Risk factors for osteoporosis
Female Small/thin Menopause Inactivity Smoking Alcohol Steroids Low Ca/VitD White/Asian
What mneumonic can be used to categorise causes of falls
DAME D - drugs A - ageing M - medical E - environmental
Medications that can increase the risk of falls
Polypharmacy Anti-hypertensives Sedatives Opioids Psychotropics Anti-hyperglycaemics Alcohol
What ageing-related changes can increase risk of falls
Vision deterioration Cognitive decline Abnormal gait OA Decreased baroreceptor sensitivity
Which medical conditions can increase the risk of falls
Hypotension Postural hypotension Arrhythmias Parkinson's disease Stroke Neuropathy Cataracts Epilepsy BPPV UTI/infection
What environmental causes of falls could you ask patients about
Walking aids
Footwear
Home hazards
Elderly patients who get dizzy when looking up indicates what pathology
Vertebrobasilar insufficiency
Peripheral (ear) causes of vertigo
Benign paroxysmal positional vertigo (BPPV)
Menieres disease
Vestibular neuritis
Acoustic neuroma/vestibular schwannoma
Central (neuro) causes of vertigo
Migraine
Brainstem ischamia
Cerebellar stroke
Multiple sclerosis
What test is used to diagnose BPPV
Dix-hallpike manoeuvre
What is used to treat BPPV
Epley manoeuvre
Typical history of BPPV
Short spells of vertigo (5-30 seconds), settle spontaneously, happen with head movement and lying down
Typical history of menieres disease
Intermittent attacks of vertigo, fluctuating hearing loss, fluctuating tinnitus
Get symptoms before the attack and vomiting
What causes menieres disease
Increased pressure in the inner ear
Difference in symptoms between vestibular neuronitis and labyrinthitis
People with labyrinthitis also get hearing loss and tinnitus
Symptoms of both vestibular neuronitis and labyrinthitis
Usually following URTI/viral illness
Sudden severe vertigo
Nausea and vomiting
Balance and concentration difficulties
The labyrinth (inner ear) contains what two main structures
Cochlea Vestibular system (semicircular canals)
Acoustic neuroma symptoms
Unilateral hearing loss
Tinnitus
Vertigo
Headache
What is an acoustic neuroma
Benign tumour of the vestibulocochlear nerve
BP drop needed to diagnose postural hypotension
Systolic drop of 20+ OR Diastolic drop of 10+ OR Systolic drops to < 90
Bedside investigations for a fall
Obs - HR, BP, RR, Sats, Temp Lying + standing BP Urine dip ECG Cognitive screening - e.g. AMT BM
Differentials for confusion
Delirium Stroke TIA SOL Cerebral bleed Dementia Constipation Dehydration Recent surgery Environmental
Causes of delirium
Dehydration Electrolyte disturbances Infection - UTI, pneumonia Urinary retention Constipation Medication/drug toxicity or withdrawal Lack of sleep Hypoglycaemia Stroke/subdural haemorrhage Hypoxic states
Definition of delirium
Acute onset of disturbed consciousness/cognitive function/perception that has a fluctuating course
What are the 3 types of delirium
Hyperactive
Hypoactive
Mixed
Management of delirium
Treat underlying cause Reassurance Reorientation to their environment Calm Establish normal sleeping pattern Close monitoring
What questions are asked in the AMT 4 (abbreviated mental test 4)
Age
DOB
Current year
Current location
What are the 4 components of the 4 AT test
Alertness
AMT 4 - age, DOB, year, location
Attention - name the months backwards
Acute + fluctuating course
What are the 4 components of CAM (confusion assessment method)
Acute onset + fluctuating course
Inattention/counting backwards
Disorganised thinking/incoherent
Altered level of consciousness
Which lobe of the brain contains brocas area
Frontal lobe
What is brocas area responsible for
Language production
Which lobe of the brain contains Wernicke’s area
Temporal lobe
What is Wernicke’s area responsible for
Language comprehension
The ACA supplies which part of the brain
Frontal and parasaggital region
The MCA supplies which part of the brain
Lateral part of the frontal and parietal lobe, superior temporal lobe
The PCA supplies which part of the brain
Occipital lobe, inferior temporal lobe, thalamus
Signs of an MCA stroke in the dominant hemisphere (left in most people)
Brocas/Wernickes/conduction aphasia
Signs of an MCA stroke in the non-dominant hemisphere (right in most people)
Hemineglect to the contralateral side (left)
Is the leg or arm more affected in an ACA stroke
Leg
What visual defect is caused by a PCA stroke
Homonymous hemianopia with macula sparing
Which parts of the brain do the vertebrobasilar arteries supply
Brainstem
Cerebellum
Which parts of the brain do the lacunar arteries supply
Basal ganglia
Internal capsule
Thalamus
Pons
Risk factors for ischaemic stroke
HTN DM IHD Smoking Carotid stenosis AF Polycythaemia Sickle cell Thrombophilia
Risk factors for haemorrhagic stroke
HTN Aneurysms AV malformations Vascular brain tumours Anticoagulation Alcohol Smoking Stress
What is the NIHSS
National Institute of Health Stroke Scale - scores stroke severity and monitors improvement
The Oxford Stroke Classification applies only to which type of stroke
Ischaemic
Criteria for a TACS (total anterior circulation stroke)
ALL OF:
Unilateral weakness/decreased sensation of face, arm, leg
Homonymous hemianopia
Higher cerebral dysfunction - dysphasia, visuospatial disorder
Criteria for a PACS (partial anterior circulation stroke)
TWO OF:
Unilateral weakness/decreased sensation of face, arm, leg
Homonymous hemianopia
Higher cerebral dysfunction - dysphasia, visuospatial disorder
Criteria for a LACS (lacunar stroke)
ONE OF: Unilateral weakness +/- sensory deficit - arm/leg+arm/al 3 Pure sensory/motor/mixed Ataxic hemiparesis WITH NO HIGHER CEREBRAL DYSFUNCTION
Criteria for a POCS (posterior circulation stroke)
ONE OF:
Cranial nerve palsy + contralateral decreased motor/sensation
Bilateral decreased motor/sensation
Conjugate eye movement - horizontal gaze palsy
Cerebellar dysfunction - vertigo, nystagmus, ataxia
Isolated homonymous hemianopia
Name some stroke mimics
Seizure Sepsis Hypoglycaemia Bell's palsy Migraine MS SOL Transverse myelitis/cord disease MND Polyneuropathies
What is the window for thrombolysis following an ischaemic stroke
Within 4.5 hours from symptom onset
Which medication is used in post-stroke thrombolysis
Alteplase
Which stroke patients do we start on anticoagulants
Those with AF
What is dysarthria
Unclear articulation of speech
What is expressive aphasia
They know what they want to say but they can’t say it
What is receptive aphasia
Their words are incomprehensible but they are unaware of it
Changes to speech in patients with MS
Slurred/scanning/staccato speech
Changes to speech in patients with Parkinson’s disease
Dysrhythmic, monotonous
Describe Wernicke’s aphasia
General comprehension deficits, word retrieval deficits, semantic paraphrasias, semantic content of language damaged but production in tact. Speech is fluent but lacks content. Patients lack awareness of their speech difficulties.
Describe Broca’s aphasia
Deficits in speech production, rhythm + syntactic comprehension. Speech is slow and halting but with good semantic content. Comprehension usually good. Patients are aware of their language difficulties.
Describe conduction aphasia
Normal speech production and comprehension but impaired ability to repeat words
TIA definition
Acute onset of focal neuro dysfunction related to a vascular territory that leave no permanent damage, symptoms often improved before they even have time to present. <24 hours to complete recovery
Definition of crescendo TIA
2 or more episodes in one week
What does the ABCD2 score assess
Risk of stroke within 2 days following a TIA
TIA differentials
Stroke
Migraine
Ophthal causes of vision loss - retinal haemorrhage, retinal detachment
Hypoglycaemia
Atypical seizures
Inner ear disorders can mimic posterior circulation TIA
What does the CHADSVASc score assess
Risk of stroke in AF patients
Causes of TIA
Embolus - carotids, heart
Vasculitis
Infective endocarditis
Risk factors for TIA
Carotid stenosis HTN DM IHD Smoking AF Polycythaemia Thrombophilias
What is the definition of malnutrition
A state of nutrition in which deficiency or excess of energy, protein and other nutrients causes measurable adverse effects on tissue or body form or function and clinical outcome
Causes of oropharyngeal dysphagia
Neuro - stroke, MS, trauma, tumour
Infectious - mucositis from chemo, candida
Muscular - myasthenia gravis, dermatomyositis
Structural - cricopharyngeal stricture, pharyngeal pouches, oropharyngeal tumour
Causes of oesophageal dysphagia
Function Achalasia Motility disorders - stroke, muscular disease Tumour Oesophagitis Stricture/rings/webs Mediastinal mass
Causes of malnutrition
Increased needs - surgery, illness
Increased loss - D+V, fever, wounds, burns
Decreased intake - appetite, dysphagia, practical issues
What score can be used to assess for malnutrition
MUST score
What 3 main things does the MUST score take into account
BMI
Unplanned weight loss
Acute illness/no intake for 5 days
A MUST score of ? is managed by observation and encouragement
1
A MUST score of ? is managed by treatment +/- dietician referral
2+
TPN is given via which vessel
Central SVC line
PPN (partial parenteral nutrition) is given via which vessel
A peripheral venous line
5 main feeding tube options
Nasogastric Nasoduodenal Nasojejunal Gastrostomy Jejunostomy
Common indications for parenteral nutrition
Mechanical dysphagia
Neurological dysphagia
Global neurological deficits
Increased nutritional requirements - e.g. malabsorption states such as CF or Crohn’s disease
How can you check the positioning of an NG tube
Aspirate stomach fluid and check pH with litmus
X-ray
What are the 4 grades of pressure ulcers
1 - skin intact but erythematous
2 - partial thickness skin loss
3 - full thickness skin loss
4 - destruction of underlying muscle/bone/fascia
Risk factors for pressure ulcers
Decrease mobility Decreased circulation Poor nutrition DM Smokers High or low BMI Medical equipment in prolonged contact with skin
Areas at high risk of pressure ulcers
Heels, hips, buttocks, elbows, back of head
What is continuing health care
Arrangement for free care outside of the hospital - arranged and funded by the NHS
What are the 3 main types of care home
Residential - personal care only
Nursing - personal and nursing care
Specialist care home for dementia - only if prominent behavioural/pscyh disorders associated with their dementia
What are the 6 categories of elder abuse
Physical Financial Psychological Sexual Discriminatory Neglect/acts of omission
What are the 4 categories of risk factors for abuse
The victim
The perpetrator
The relationship
Environmental
What is pharmacodynamics
What the drug does to the body
What is pharmacokinetics
What the body does to the drug
What 4 main processes are involved in pharmacokinetics
Absorption
Distribution
Metabolism
Excretion
What is the definition of polypharmacy
5+ drugs
Examples of prescribing cascades
Codeine - constipation - senna
Amlodipine - oedema - diuretic
Statin - muscle pain - analgesia
What tool can be used in medication reviews
STOPP/START toolkit
Lewy bodies are made up of which protein
alpha-synuclein protein
Patho of Parkinson’s disease
Lose of dopaminergic neurones in the substantia nigra and lewy body build up –> decreased dopamine delivery to the basal ganglia –> decreased excitatory input to cortical areas of motor control
Symptoms in the Parkinsonism triad (+ pentad)
- Resting tremor
- Bradykinesia
- Rigidity
- Postural/gait instability
Differentials for tremor
Parkinsonism Essential Cerebellar Hyperthyroidism Medication induced Flapping Alcohol withdrawal
Character of parkinson’s disease tremor
Fine, unilateral/asymmetrical, worse at rest
Character of essential tremor
Coarse, worse on movement, improved by alcohol, often FH
Character of cerebellar tremor
Intention tremor
What causes a tremor that is worse on movement
Essential
Hyperthyroidism
Medication induced
Causes of a flapping tremor
Liver disease
CO2 retention
Differentials for Parkinonsim
Idiopathic PD
Vascular parkinsonism
Lewy body dementia
Medication induced - antipsychotics, metoclopramide
MSA - multisystem atrophy (early autonomic features)
PSP - progressive supranuclear palsy
Normal pressure hydrocephalus
Motor features of Parkinson’s disease
Bradykinesia Akinesia (freezing) Resting tremor Pin rolling tremor Micrographia Low blink rate Hypophonia Parkinsonian gait Rigidity Normal reflexes Difficulty turning in bed Decreased facial expression
Describe a Parkinsonian gait
Stooped posture
Shuffling
Reduced arm swing
Non-motor features of Parkinson’s disease
Constipation Urinary urgency Uncontrolled saliva production Swallowing difficulties Back pain Poor sleep Vivid dreams/nightmares Short term memory and recall loss Anxiety Depression
How can you elicit bradykinesia in a patient with PD
Ask them to repeatedly pinch their fingers together or tap their foot
How can you elicit/exaggerate tremor in a patient with PD
Ask them to move their other arm up and down repeatedly
Which two enzymes break down dopamine in the synapse
MAO (monoaminde oxidase)
COMT (catechol-o-methyltransferase)
Which enzyme breaks down dopamine in the periphery
DOPA Decarboxylase
Name of a DOPA decarboxylase inhibitor
Carbidopa
Benserazide
Name of a COMT inhibitor
Entecapone
Name of an MAO inhibitor
Rasagaline
How do we treat essential tremor
Beta-blockers
2 problems that can occur after having use levodopa/Parkinon’s meds for a long time
On-off phenomena
Peak dose dyskinesias
