Care of the Elderly Peer Teaching Flashcards
Which is the most common type of dementia?
Alzheimer’s disease
What are the 5 A’s of Alzheimer’s Disease?
- Amnesia
- Aphasia
- Apraxia
- Agnosia
- Apathy
Describe the pathophysiology of Alzheimer’s disease.
- Global atrophy
- Intra-cellular neurofibrillary tangles made from tau protein -> disrupt microtubules in the nerves
- Extracellular beta-amyloid plaques -> disrupt nerve communication at synapses
- > causes nerve degeneration
Treatment for Alzheimer’s?
Anticholinesterase inhibitors:
- Donepezil
- Rivastigmine
- Galantine
Pt has receptive aphasia. How do they present?
- Difficulty comprehending
- > Wernicke’s area
A patient has expressive aphasia. How do they present?
- Difficulty producing language
- > Broca’s area
Describe Lewy Body Dementia.
- Day-to-day fluctuating cognition
- Visual hallucinations
- Sleep disturbance
- Recurrent falls
- Parkinsons
- DO NOT PRESCRIBE NEUROLEPTIC DRUGS AS THIS MAKES DLB PATIENTS WORSE
Describe Vascular Dementia
- No atherosclerotic risk factors; multiple cerebral infarcts
- Step-wise deterioration in cognition
- Can get focal neurology
- Fits
- Nocturnal confusion
Describe Pick’s disease.
A type of fronto-temporal dementia
- disinhibition
- antisocial behaviour
- personality changes
- knife-blade atrophy
Describe normal pressure hydrocephalus
‘Wet, Wacky, Wobbly’
- Urinary incontinence
- Dementia
- Gait disturbance
- > due to increased CSF, but ventricles dilate
Name 3 cognitive assessment tools, other than MMSE.
- Addenbrooke’s cognitive examination III (ACE-III)
- Montreal Cognitive Assessment (MOCA)
- Abbreviated Mental Test Score (AMT)
- 6-item cognitive impairment test (6-CIT)
- General Practitioner Assessment of Cognition (GP COG)
What is mild cognitive impairment?
- Cognitive impairment but minimal impairment of ADLs.
Define delirium.
Acute, transient, reversible state of fluctuating impairment of consciousness, cognition and perception.
What are the 2 types of delirium?
- Hyperactive: agitation, inappropriate behaviour, hallucinations
- Hypoactive: lethargy, reduced concentration.
Name 5 causes of Delirium.
D = Drug use (anticholinergics, opioids) E = Electrolyte abnormalities L = Lack of drug (withdrawal) I = Infection eg. UTI, Pneumonia R = Reduced sensory input (blind, deaf) I = intracranial problems (stroke, post-ictal) U = Urinary retention + constipation M = Malnutrition (thiamine, Nicotinic acid, B12 deficiency
Define ‘delusion’.
- A fixed, false belief, held with conviction
- Cannot be altered with evidence / proof
- Is inappropriate according to the social / cultural norm.
What does a Delirium screen involve?
Bloods:
- FBC (WCC for infection, Anaemia, MCV)
- U+Es (urea, AKI or Na+ / K+)
- LFT (liver failure, or alcohol abuse)
- Blood glucose
- TFTs (hypothyroid)
- Increased Calcium (Bones, stones, moans + groans)
- Haematinics (B12 and Folate)
- INR (Warfarin, Bleeding risk)
What does a septic screen involve?
- Urine Dipstick
- CXR
- Blood Cultures
- ABG - Lactate
- Bloods - ?infection
- Lumbar puncture
- ECG
How would you manage a patient with Delirium?
Supportive Mx: alter the environment to help with re-orientation
- Clocks + calendars
- side room
- Sleep hygiene: discourage napping
- Adequate lighting
- Continuity of care
- Access to hearing aids / glasses
Medical treatment for Delirium?
- Try to avoid, if possible *
- IM Haloperidol (antipsychotic)
- Benzodiazepines
Describe a full Comprehensive Geriatric Assessment for Discharge planning.
- Medical assessment: diagnosis + treatment, co-morbid conditions + disease severity, meds review - Doctor / Consultant
- Functional Assessment: ADL, Gait, balance - OT, Physio
- Psychological assessment: Cognition, Mood - Nurse, Psychiatrist
- Social assessment: Care resources, finances - Social worker
- Environmental assessment - Home safety team
Define ‘Osteoporosis’.
- Decreased bone mineral density
- Increased bone fragility
- > leads to fractures
Define ‘osteopenia’.
precursor to osteoporosis.
Define ‘osteomalacia’.
Softening of bones due to impaired bone metabolism from inadequate levels of Calcium, Phosphate and Vitamin D
What does ‘DEXA’ stand for?
Dual-energy X-ray Absorptiometry
What is the WHO osteoporosis criteria?
T score
0 to -1 is normal
- 1 to -2.5 = osteopenia (give lifestyle measures)
- Less than 2.5 = osteoporosis
What is the T score (in relation to Osteoporosis)?
The number of Standard deviations the patients’ bone mineral density differed from the population average for a young, health adult.
When would a spinal x-ray be used?
- Useful to assess vertebral crush fractures
- Can’t assess the extent of osteoporosis.
- Low sensitivity and specificity.
Describe the bone profile of someone with osteoporosis.
- Bone profile is normal
- > Calcium, Phosphate and Alk phos are all normal.
- Bloods can help identify cause / risk factors for osteoporosis.
What is the relationship between Vitamin D + Osteoporosis?
Low Vitamin D levels contribute to osteoporosis.
In measuring Vit D levels, one cannot assess the extent of osteoporosis.
List risk factors for Osteoporosis.
"SHATTERED" Steroids (>5mg/day) Hyperthyroidism, hyperparathyroidism, hypocalcaemia Alcohol / tobacco Thin (BMI < 22) Testosterone decreased Early menopause (oestrogen deficiency) Renal / Liver failure Erosive / inflammatory bowel disease Dietary intake (Decreased Calcium, Malabsorption, Diabetes Type 1)
What are the actions of parathyroid hormone?
- Increases osteoclast activity - releases Calcium and Phosphate from bones
- Increases Calcium reabsorption but decreases phosphate reabsorption from the kidneys
- Active Vitamin D production is increased - increases Calcium absorption from the gut and decreases phosphate.
What is the action of Vitamin D in the body?
increase calcium absorption from the gut.
Conservative treatment for osteoporosis?
- Decrease risk factors (stop smoking, alcohol, weight, Calcium, Vit D supplements)
- Weight-bearing exercises
- Falls prevention - balance exercises
- Home assessment
Medical treatment for Osteoporosis?
- Bisphosphonates
- Strontium Ranelate -> forms bone
- Raloxifine (SERM)
- Calcitonin - reduce pain after fractures
- Denosumab - monoclonal to RANK ligand, SC twice yearly.
- RANK ligand activate osteoclasts.
A patient is started on Bisphosphonates. What instructions should you give the patient & what are the Side effects of bisphosphonates?
- Swallow pills with plenty of water. Remain upright for 30 minutes, before eating.
SE:
- Oesophageal ulcers
- Jaw osteonecrosis
- Photosensitivity
- GI upset
Define Syncope.
Temporary loss of consciousness, characterised by:
- fast onset
- short duration
- spontaneous recovery
- due to hypoperfusion of the brain.
List some causes of collapse / syncope.
- Neuro
- CVS
- Drugs
- Other (Endocrine)
List some risk factors for falls.
- Motor problems: gait / balance
- Sensory impairment
- Cognitive / Mood impairment: dementia, delirium
- Orthostatic hypotension
- Polypharmacy
- Alcohol / drugs
- Environmental hazards: poor lighting
- Incontinence
- Fear of falling
What metabolite changes does muscle breakdown cause?
Increased:
- Potassium
- Phosphate
- Myoglobin
- Creatinine Kinase
Why is myoglobin harmful to the kidneys?
Causes acute tubular necrosis
What does raised Potassium run the risk of?
Increased risk of arrhythmias -> do an ECG
Define rhabdomyolysis.
Skeletal muscle breaks down due to traumatic, chemical or metabolic injury
List some causes of Rhabdomyolysis.
- Crush injuries
- Prolonged immobilisation following a fall
- Prolonged seizure activity
- Hyperthermia
- Neuroleptic Malignant Syndrome
What is the Mx of someone who is suspected of undergoing rhabdomyolysis?
- Supportive
- IV fluids
- Correction of electrolytes
- Renal replacement therapy
What ECG changes would you see if someone had Hyperkalaemia?
- Peaked T waves
- Prolonged PR segment
- Loss of p waves
- Broad QRS
- ST elevation
- Sine wave pattern
- Ventricular fibrillation
Management of Hyperkalaemia?
C BIG K DROP
- Calcium glutinate (cardioprotective)
- Bicarbonates
- Insulin
- Glucose (drives Potassium into cells)
- Kayexalate (binds K+ in the GI tract_
- Diuretics if kidneys are ok
- Renal - dialysis if kidneys are not ok :(
Define ‘ulcer’.
A break in the skin or mucous membrane which fails to heal
A pressure ulcer is caused by pressure or shear force over a bony prominence.
List some risk factors for pressure ulcers.
- Immobility - bed bound
- Poor nutrition
- Incontinence
- Multiple co-morbidities
- Smoking
- Dehydration
Which risk score is used to assess the risk of developing a pressure ulcer?
Waterlow Score - assess risk of developing a pressure ulcer
List some methods of preventing pressure ulcers.
- Barrier creams
- Pressure redistribution -> special foam mattresses
- Repositioning
- Regular skin assessment.
What comprises a ‘regular skin assessment’ (in relation to preventing pressure ulcers)?
- Check for areas of pain or discomfort
- Skin integrity at pressure areas
- Colour changes
- Variations in heat, firmness and moisture (eg. incontinence, oedema, dry, inflamed skin
