care of the elderly

Question 1

what is the CAM (confusion assessment method) based on ICD 10 criteria for diagnosing delirium

Answer 1

1. acute onset and fluctuating course
   plus
2. inattention (counting backwards or in interview)
   and any of
3. disorganised thinking
4. altered consciousness level (more or less alert)

Question 2

first line when patient becomes distressed or agitated?

Answer 2

de-escalation methods including
reassurance, increased nursing care including one to one care, eye contact, comforting
LOOK FOR UNDERLYING CAUSE

then haloperidol 0.5mg IM as sedative if the patient is at risk of harming themselves or others

Question 3

name some general measures for treating an older person with delirium

Answer 3

1. reassurance, re-orientation, calm environments
2. encourage oral intake of food and drink and record these on the fluid balance charts and food charts
3. encourage mobility
4. continued AMTS scoring
5. follow up in community with regarding dementia (as delirium episodes put one more at risk of developing dementia later on )
6. increased nursing observation while in hosp

Question 4

If a patient is confused and is not responding to de-escalation methods, then what do you do ?

Answer 4

IM 0.5 mg- 1 g Haloperidol . start at a low dose and hopefully they would only need to be on it short term (ideally less than a week)
Olanzapine could be used instead
or lorazepam if these are contraindicated

Question 5

when is haloperidol contraindicated?

Answer 5

in parkinsons disease and Lewy Body dementia
in this case it would be more appropriate to use LORAZEPAM

nb remember to ask about alcohol intake as if this is n alcohol withdrawal delirium, first line would be a BDZ such as chlordiazepoxide

Question 6

what should you do if a patient is not responding to the haloperidol and is still delirious>

Answer 6

• re-evaluate for possible causes of delirium

- consider follow up/assessment for dementia

Question 7

how many patients on medical wards suffer an episode of delirium?

Answer 7

30%

Question 8

define delirium

Answer 8

delirium is an acute onset of disturbed consciousness (characterised by hypo or hyperalertness), cognitive impairment or impairment of perception , with a fluctuating course
it usually comes on over the period of a couple of days

Question 9

features of hypoactive delirium

Answer 9

• increased sleeping
• quiet and withdrawn behaviour
• drowsiness
• classic hand movements

Question 10

features of hyperactive delirium

Answer 10

• agitation
• heightened arousal
• restlessness
• aggression

Question 11

risk factors for delirium

Answer 11

• over 65 yrs
• current hip fracture
• severe illness
• dementia diagnoses
• sensory impairment
• frailty

Question 12

precipitants of delirium

Answer 12

• surgery
• drugs
• infection
• urinary retention
• constipation
• pain

Question 13

good tools for junior doctors to diagnose delirium?

Answer 13

-4AT test or CAM test

Question 14

score to calculate risk of stroke post TIA

-what factors are taken into account

Answer 14

ABCD2 score
a= age >60
b= blood pressure >140/90
c=clinical features of the TIA
-unilateral weakness 2
-speech disturbance without weakness 1
d=
-diabetes 1
-duration of symptoms >60 min 2
>10 min 1

Question 15

features of MSA

how is it treated

Answer 15

• parkinsonism
• autonomic signs (atonic bladder, postural hypotension)
• cerebellar signs (ataxia)

treated with levodopa and supportive measures

Question 16

features of normal pressure hydrocephalus

how is it treated?

Answer 16

gait ataxia
dementia
urinary incontinence

treated with:
diagnostic lumbar puncture
CSF removal
ventriculo-peritoneal shunt

Question 17

features of vascular parkinsonism

Answer 17

arteriosclerotic, pt may have had a stroke, have vascular risk factors
-may swing arms less than PD
-lower body symptoms : rigidity of lower limbs,
gait ataxia, urinary problems
-memory problems
-tremor is less common,
lack of facial expression

50% respond to levodopa

Question 18

dementia with lewy body feature

Answer 18

-dementia
-visual hallucinations (prominent)
-parkinsonism
fluctuations in alertness

shared care: psychiatry, neurology, geriatrics

Question 19

corticobasal degeneration features

Answer 19

dyspraxia
asymmetrical parkinson symptoms
cortical sensory impairment
alien limb phenomenon
does not respond well to levodopa

Question 20

supranuclear palsy features

investigations

treatments

Answer 20

symptoms:
impaired vertical gaze
early falls
truncal rigidity
speech disturbance

investigation: MRI scan. midbrain atrophy look for hummingbird sign

treatment
speech and language review and supportive measures

Question 21

drug induced parkinsonism features

Answer 21

hx dopaminergic blocking drugs eg antipsychotics or metoclopramide
symmetrical parkinson features and rigidity
blank facial expression

Question 22

features of parkinsons disease

treatments

Answer 22

assymetrical
bradykinesia
tremor 
rigidity
postural instability

treated with levodopa or dopamine agonists

Question 23

how would you make a diagnosis of idiopathic parkinsons disease

Answer 23

Bradykinesia PLUS at least one of

• postural instability (not explained better by another cause)
• resting tremor (asymmetrical) 4-6Hz
• muscular rigidity

2. exclude other causes
3. supporting factors include: (need 3 )
   - excellent levodopa response
   - levodopa induced chorea
   - unilateral onset
   - progressive disorder
   - progression 10 yrs or more
   - levodopa response 5 yrs or more
   - continued asymmetry
   - rest tremor present

Question 24

frequency of a parkinsonian tremor

Answer 24

4-6 hz

Question 25

non motor symptoms of parkinsons disease

Answer 25

olfactory dysfunction
cognitive impairment
autonomic disturbance (constipation, 
pain
fatigue
sleep disturbance
low mood 
swallowing difficulties

Question 26

Risk factors for pressure ulcers

Answer 26

limited mobility
Limited sensation
Nutritional deficiency
Inability to reposition oneself
Terminal illness
Chronic illness
Smoking
Dry skin
Old age >70
Cognitive impairment