Care Of The Eldrely Flashcards
1
Q
Differences between delirium and dementia ?
A
Delirium Acute onset Fluctuating course Impaired attention Decreased consciousness Usually reversible Often accompanies physical illness Hospital acquired
Dementia Chronic illness Progressive course Preserved attention Consciousness preserved Irreversible No underlying medical cause
2
Q
Common causes of delirium? More rare causes?
A
Commonly: UTIs (and other infections) opiate side-effects (and other drugs) alcohol withdrawal hypoglycaemia hypoxia TBI post-op postictal dehydration
Rarely: hyper/hypothyroidism, Cushing’s, CVA, Addison’s, Urinary retention, heart failure, constipation, B vitamin deficiency, porphyrias,
3
Q
Management of delirium ? Aggression drugs? What needs to be considered with drugs?
A
Adapt the ward to keep patients well orientated in time and place
-big clocks, well lit …
Optimise management - Eg Fluid monitoring / SaO2
Identify and treat underlying causes
Aggression -> de escalate and talk down
Medication - 1st -lorazepam oral and IV/IM
-then can try olanzapine, promethazine or haloperidol
Drugs are not a long term solution - max 1 week ideally
4
Q
Dementia investigations in primary care? Screening tools? Tests for sub types? Secondary care ix?
A
FBC, U&Es, LFTs, eGFR, TFT, b12 and folate, urine, HbA1C,
Referral to specialist memory services
MMSE, 6-CIT, GPCOG
Subtype: ICD-10 and DSM-V
-special tests Eg Luria’s 3 step / FAB
Secondary care imaging - MRI>CT
5
Q
How do you differentiate AD, VD and FTD ?
A
perfusion hexamethylpropyleneamine oxime (HMPAO) single-photon emission computed tomography (SPECT)
6
Q
What is Luria’s 3 step test?
A
Patient asked to tap table with fist then open palm then side of open hand
Then repeat as fast as they can
7
Q
What is the FAB test? What is is used for?
A
Frontal assessment battery
Differentiating between frontal type and AD
8
Q
What criteria is used in AD diagnosis? What MMSE scores for mild / moderate / severe and drugs used?
A
NINCDS-ADRDA criteria
Mild (21-24), moderate (10-21) Acetylcholinesterase inhibitors (rivastigmine, donepazil, galantamine)
Severe (<10) NMDA antagonists (memantine)
9
Q
What tool used for screeening of vascular dementia?
A
NINDS-AIREN criteria
10
Q
What are Lewy bodies? Screen with? How do you minimise Parkinsonism?
A
Clumps of alpha-synuclein protein
International Consensu for LBD screening tool
Levodopa
11
Q
Screening tool for FTD
A
Lund-Manchester screening tool
12
Q
What causes Korsakoffs psychosis? Sx?
A
Chronic thiamine (b1) deficiency - usually due to alcoholism
Severe memory loss with confabulation, apathy and a lack of insight
13
Q
Reversible causes of dementia ?
A
Psudodementia B12/ folate deficiency Hypothyroidism Syphilis Paraphernia Lyme disease NPH
14
Q
Medical causes of falls risk? Social causes?
A
Weakness Poor vision Dizziness - CV and polypharmacy Loss of coordination Stiffness / joint function Delirium and cognitive impairment Incontinence
Social
Loss o mobility aids
Home hazards
Insufficient care
15
Q
Medical consequences of falls? Social consequences/
A
Fracture
Heat injury
Social - fear/ anxiety, loss of independence, Medically fit for discharge patient (MFFD)
16
Q
What is the difference between osteoporosis and osteomalacia?
A
Osteoporosis is an imbalance between bone remodelling and bone resorption, resulting in reduced bone mineral density
Osteomalacia (adult rickets) is the failure to adequately mineralise your bone, due to calcium or vitamin D deficiency
17
Q
Risk factors for osteoporosis?
A
Elderly smoking Early, untreated menopause Underweight Inactivity Alcohol
18
Q
Tool to estimate fragility fractures risk assessment?
A
FRAX - 10 year fracture risk
19
Q
Common fractures in osteoporosis?
A
Spinal
NOF
Wrist
(Low blood flow ???)
20
Q
Osteoporosis ix? What does the scan tell you? What diagnosis if there is reduced density but not at a level for osteoporosis?
A
Bloods - calcium and Vit D
Bone mineral density - DEXA scan (dual-energy-X-ray-absoptiometry)
Gives you a T-score (comparison between the BMD between patient and what’s Normal for their age/gender
Osteopenia
21
Q
Management of osteoporosis?
A
Reduce risk of falling
-social, polypharmacy, balance and strengthening exercises
Reduce risk of fractures if they do fall
-milk, bisphosphonates
22
Q
Mnemonic for causes of delirium
A
DELIRIUM
Drug use (introduction, dose adjustments)
Electrolyte and physiological abnormalities
Lack of drug (withdrawal)
Infection
Reduced sensory input (blind, deaf, changing env.)
Intracranial problems (stroke, post-ictal, meningitis, subdural haem.)
Urinary retention and faecal impaction
Myocardial (MI, arrhythmia, HF)
23
Q
Ways of managing the environment in delirium?
A
Soft lighting Clocks and calendars Sleep hygiene - night time sleeping Avoid multiple rooms / wards Minimise provocation
24
Q
Patient came in with UTI and subsequent delirium maybe over the top of dementia. After managing UTI her MMSE score has improved but she is still confused
What are the next steps? What is this? Aspects of it?
A
Comprehensive geriatric assessment
Identifies health problems and establishes management plans in older patients with frailty
“An interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old
The aim is to develop a coordinated, integrated plan for treatment and long-term support”
Physical health - includes pain and underlying illness
-Medication review
Mental health - memory, mood cognition, capacity
Social aspects
- informal (family, friends)
- formal (social services, meals, day care)
[SPF ME - aspects]
Functional aspects - can they use public transport / technology?
Environment - state of housing, facilities
25
Who is in the CGA team?
```
Chair
OT
Geriatrician
Social worker
Physiotherapist
```
26
Jasper is 76. He has a left hemiparesis from a previous stroke
Brought to A&E by home carer having fallen in the bathroom at home
He was on floor for 18 hours as he could not get up
What are the complications of a long lie following a fall?
Pressure ulcers
Dehydration
Rhabdomyelosis - damaged skeletal muscle breaks down rapidly
-> muscle pain, weakness, confusion, vomiting
-> tea coloured urine and arrhythmia
-> myoglobin can -> kidney failure
27
Pressure ulcers Ix? Mx?
```
Ix:
CRP, ESR
WCC
Swabs
Blood cultures
X-ray for bone involvement
```
```
Management:
Antibiotics
Wound dressing
Pain relief
Debridement if grade 3/4
```
28
Bleeding from gums and excessive bruising - diagnosis? Mx? How do you assess nutritional status?
what are the methods of feeding ?
Vit C deficiency
Correct deficiency and MDT approach to address malnourishment
MUST screening tool
Oral, PEG, total parental nutrition
29
What is reseeding syndrome? Biochemical features?
Complications?
Mx?
Metabolic disturbance as a result of reinstitution of nutrition to patients who are starved / severely malnourished
```
Biochemical features
Hypophotphataemia
Hypokalaemia
Thiamine deficiency
Abnormal glucose metabolism
```
Complications
Arrhythmia, coma, seizures, cardiac failure
Mx
Monitor blood biochemical
Commence refereeing with guidelines
30
4 I’s of geriatrics
Immobility
Incontinence
Incompetence
Impaired homeostasis
31
85 year old man with 2/12 Hx diarrhoea. Wife noticed decline in cognition. Palpable liver edge. Urine dip shows nitrites, protein and leucocytes. On admission, he is very confused.
Give 2 causes for his confusion
What test would you do to assess his mental state?
What 3 things could the nurses do to help?
Wife unable to cope at home.
How would you assess the situation before discharge?
Infection / metabolic abnormalities, old age
MMSE
Clocks, good lighting, not move room / ward
CGA, MDT input, cares, physio, occupational therapy
32
Causes of falls in elderly people (at least 5)
Drugs (e.g. sedatives, alcohol)
MSK (e.g. OA of hip)
Syncope (e.g. vasovagal, cardiogenic, arrhythmias)
Stroke/TIA
Postural hypotension (secondary to antihypertensives, hypovolaemia, dopaminergic drugs)
Vertigo (e.g. BPV, meniere’s disease)
Neurological: peripheral neuropathy, Parkinson’s
Hypoglycaemia
Poor environment (e.g. poor lighting, loose rugs)
Visual impairment
Dementia
33
As Sweeney enters the consultation room, you notice he has a very slow-shuffling gait and a mask-like, expressionless face.
What is your top differential diagnosis?
What are the 3 main features of Parkinson’s?
List 3 differentiating features of a parkinsonian tremor.
Tremor
Bradykinesia
Rigidity - lead pipe / cogwheel
```
Slow (pill-rolling)
Worse at rest
Asymmetrical
Reduced on distraction
Reduced on movement
```
34
```
What is the underlying pathophysiology of Parkinson’s?
What class of drug is normally combined with L-dopa to prevent peripheral side-effects?
Name 3 complications of L-dopa therapy.
```
Loss of dopaminergic neurones in the substantia nigra
Dopa decarboxylase inhibitor (eg carbidopa / benserazide)
Complications
Postural hypotension on starting treatment
Confusion, hallucinations
L-dopa induced dyskinesias
On-off effect: fluctuations in motor performance between normal function (on) and restricted mobility (off).
Shortening duration of action of each dose (i.e. end-dose deterioration where dyskinesias become more prominent at the end of the duration of action)
35
Bar blood and bedside what are 2 crucial ix in TIA?
```
ECG
MRI head (or if MRI is CI -> CT)
```
36
```
Immediate management of stroke?
Long term (secondary prevention)?
```
ABCDE assessment
Aspirin 300mg daily - with PPI if indicated
Specialist assessment and investigation within 24 hours of symptom onset
Specialist assessment within 1 week if suspected TIA 1 week ago
```
Long term
Lifestyle
Clopidogrel 75mg daily
Statins, (antihypertensives if needed)
Warfarin / NOAC - if AF, mitral stenosis dilated cardiomyopathy, recent big septal MI
```
37
Prevention of a pressure ulcer?
Barrier creams
Pressure redistribution and a friction cushion - special mattress, heel support, cushions
Repositioning - every 6 hours in normal risk, every 4 in high risk
Regular skin assessment
-check for areas of pain / discomfort
-colour changes
-variations in heat, firmness and moisture Eg incontinence, oedema, dry / inflamed skin
38
Name 4 cardiac conditions that may cause an emboli CVA
```
AF
MI causing mural thrombus
Infective endocarditis
Aortic / mitral valve disease
Patient forman ovale
```
39
What colour does a haemorrhage appear on CT?>
White
| Vascular occlusion - black
40
Other than an ECG and CT head what other investigations might you do in a stroke and why?
Clotting screen (may indicate increased risk of thrombosis or haemorrhage)
Syphillis serology (to exclude neurosyphillis)
Echocardiogram (to exclude cardiac sources of emboli)
Carotid doppler (to exclude internal carotid stenosis)
41
Usual speed of tremor in Parkinson’s?>
3-5 Hz
42
2 classes of drug for Parkinson’s
Dopamine receptor antagonists
Levodopa
43
Egs of dopamine receptor antagonists
Which ones do you have to be careful with and why?
What should you do prior to treatment with them?
Bromocriptine, ropinirole, cabergoline, apomorphine
Ergot derived (bromocriptine / cabergoline) associated with cardiac, pulmonary and retroperitoneal fibrosis
- > must do a echocardiogram, ESR, creatinine and chest X-ray prior to treatment
- >close monitoring
44
General side effects of dopamine receptor antagonists?
```
Impulse control disorders
Excessive daytime somnolence
Hallucinations
Postural hypotension
Nasal congestion
```
45
What is usually combined with levo dopa and why? How long is Ldopa effective for? Side effects?
Decarboxylase inhibitor (carbidopa / benserazide) to prevent peripheral metabolism of levo dopa to dopamine
Around 2 years
```
Dyskinesia (involuntary writhing movements)
On-off effect
Dry mouth
Postural hypotension
Psychosis drowsiness
Anorexia
Palpitations
```
46
Bar dopamine receptor agonists and L dopa what other classes of drug are useful in Parkinson’s
MAO-B inhibitors (inhibits dopamine breakdown)
COMT Inhibitors (inhibits dopamine breakdown, adjunct to Levodopa)
Antimuscarinics (help with tremor and rigidity)
Amantidine (thought to increase dopamine relase and prevent reuptake at synapses)
47
Features of brainstep infarction
May result in severe sx
- quadriplegia
- locked in syndrome
48
What are lacunar infarcts? Sx?
Small infarcts around the basal ganglia, internal capsule, thalamus and pons
May result in pure motor, pure sensory, mixed motor and sensory signs or ataxia
49
Acute stroke mx?
ABCDE assessment
Urgent neuroimaging to rule out haemorrhagic stroke.
Thrombolysis (e.g. alteplase)
Within 4.5h of symptom onset
Not had a previous intracranial haemorrhage, uncontrolled hypertension, pregnant etc.
Aspirin 300mg ASAP and antiplatelet therapy should be continued.
50
Management of TIA with ABCD2 ≥ 4? <4
Aspirin 300mg daily stat
Specialist referral within 24 hours of sx
Secondary prevention
Specialist referral within 1 week
Vascular territory / pathology uncertain -> brain imaging
Crescendo TIAs (2 in a week) -> mx as high risk
51
Mrs. Mulberry, an 82-year old widow, is brought into A&E after her carer found her that afternoon still in bed and more confused than ever. On examination, her GCS was 11/15 and she had a temperature of 38.6oC. Her BP was 116/54mmHg, her HR 90bpm and regular; RR 28/min and there is bronchial breathing at her right base.
What are the components of the GCS?
List 6 causes of delirium.
List 3 non-invasive investigations you would do and why?
Best verbal, motor, eye opening
Infection (commonly UTI and pneumonia)
Metabolic (hypoglycaemia, renal failure, liver failure, electrolyte imbalance e.g. hyponatriaemia, hypocalcaemia.
Drugs: benzodiazepines, opiates, alcohol
Hypoxia
MI
Intracranial lesion (incl. space-occupying, epilepsy, CVA, head injury)
Nutritional deficiency (vitamin B12, thiamine)
CXR - exclude pneumonia
ECG - exclude MI
Urine dipstick - exclude UTI
52
2 categories and name at least 4 causes of hyponatraemia
Dilutional effect
Heat failure, hypoproteinaemia, SIADH, oliguria
Sodium loss
Addison’s, D&V, osmotic diuresis (diabetes / Diuretic), serve burn, diuretic stage of acute renal failure
53
At least 4 sx of hypocalcaemia?
Paraesthesia (usually fingers, toes and around mouth).
Tetany.
Carpopedal spasm (wrist flexion and fingers drawn together).
Muscle cramps
Seizures.
Prolonged QT
Laryngospasm; bronchospasm
54
At least 4 sx of hypercalcaemia ?
Bones, stones, moans and groans
Bone pain, fractures (hyper parathyroid / malignancy)
Renal stones, colic, impairment
Drowsiness, delirium, coma, muscle weakness, depression, cognitive defect
Nausea vomiting, weight loss, anorexia, abdo pain
HTN, shortened QT, arrythmias
55
6 cognitive tests?
MMSE
Addenbrookes cognitive examination-III (ACE-III)
Montreal cognitive assessment (MoCA)
Abbreviated mental test score (AMT)
6-Item cognitive impairment test (6CIT)
General practitioner assessment of cognition (GPCOG)
56
4 blood tests to exclude treatable causes of dementia?
```
Thyroid function tests
Syphilis serology (neurosyphilis)
Liver function tests (hepatic encephalopathy; alcoholism)
Vitamin B12, thiamine (B1) and folate levels
```
57
Blood test / radiological ix in delirium ?
FBC: infection n / anaemia
- LFT: hepatic failure
- U&E: AKI / metabolic disturbance (hyponatraemia, hypokalaemia)
- Calcium
- CRP/ESR
- Sputum culture: chest infection
- Folate, B12
- HbA1C
- TFT
CXR: pneumonia / heart failure
ECG: arrythmias
urinalysis: infection / hyperglycaemia
Drug levels: Eg digoxin, lithium, alcohol
58
Delirium DDX?
```
Depression
Dementia
Mental illness
Anxiety
Thyroid disease
Temporal lobe epilepsy
Charles bonnet syndrome
```
59
CI to using low dose haloperidol in delirium?
LB dementia, Parkinsonism, prolonged QT
60
Reorientation strategies in delirium ? What other 2 key things would you do?
Regular (at least three times a day) cues (for example explaining to the person who and where they are).
Easily visible and accurate clocks and calendars.
Continuity of care from carers and nursing staff.
Encouraging visits from family or friends and exposure to familiar objects.
Maintain safe mobility:
Avoid physical restraints such as cot sides.
Encourage walking at least 3 times a day (provide walking aids if needed) or, if the person is unable to mobilize, try active range of motion exercises.
Normalize the sleep-wake cycle by:
Discouraging napping and encouraging bright light exposure in the daytime.
Encouraging uninterrupted sleep at night with a quiet room and low level lighting.
61
Non medical management of Dementia ?
Aromatherapy
Music and dance
Pets and animal contact
Massage
62
A 73-year-old comes to see you asking if she can stop her alendronic acid. She has been taking it for 6 years having had a distal radial fracture at this time, after she tripped over on an uneven kerb. There have been no further fractures, nor any preceding this injury. 6 years ago, her DEXA scan showed a T-score of -2.4. Her PMHx is otherwise unremarkable and she has no recent history of falls. She has never smoked.What is the appropriate action to discuss with the patient?
Stop the bisphosphonates for 1 year and then re-introduce it at the same dose.
Switch to once yearly preparation (zoledronate) for convenience in this age group.
Continue bisphosphonate give history of fragility fracture.
Stop the bisphosphonate for 3 years and repeat DEXA scan at this point to decide on further treatment.
Repeat DEXA scan and FRAX score now and stop the bisphosphonate if low risk/T score is now >2.5, and review in 2 years
When would someone fall into a high risk group? How would this affect your plan?
Repeat DEXA scan and FRAX score now and stop the bisphosphonate if low risk/T score is now >2.5, and review in 2 years.
After a 5year period for oral bisphosphonates (3years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.
```
High risk:
corticoid therapy
Age >75
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score treatment should be continued indefinitely, or until the criteria no longer apply. If they are low risk, treatment may be discontinued and re-assessed after 2years, or if a further fracture occurs.
```
63
How do bisphosphonates work?
Clinical uses?
List 3 adverse effects of bisphosphonates.
Bisphosphonates are analogues of pyrophosphate, a molecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis.
```
Clinical uses
prevention and treatment of osteoporosis
hypercalcaemia
Paget's disease
pain from bone metatases
```
Adverse effects
oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
64
What advice do you need to give for people taking bisphosphonates?
'Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet
65
DEXA scan T scores for osteoporosis, osteopenia, healthy
-1 to +1 = healthy
-2.5 to -1 = osteopenia
>-2.5 = osteoporosis
>-2.5 + fracture = severe osteoporosis
66
What is malnutrition ? Causes?
| Requirements for diagnosis?
State in which a deficiency of energy, protein, and/or other nutrients causes measurable adverse effects on the body’s form, composition, function and clinical outcome. (NICE 2006)
Causes
Decreased nutrient intake (starvation)
Increased nutrient requirements (sepsis or injury)
Inability to utilise ingested nutrients (malabsorption)
BMI <18.5kg/m2
Unintentional weight loss >10% last 3-6mths
BMI <20kg/m2 AND unintentional weight loss >5% within last 3-6mths
67
Malnutrition 2 of each...
Factors that affect intake?
Factors that cause increased requirements?
Factors increasing loss?
```
Intake
Environment
Meal times
Food temp, smell, sounds
Feeding problems
Unfamiliar foods
Appetite, apathy, anxiety
Pain
Surgery
Medication
Radiotherapy
```
```
Increased requirements
Acute infection/pyrexia
Inflammatory condition
Trauma
Liver disease
Wound healing
Surgery
Malignancy
Chronic infection (e.g. HIV)
```
```
Increasing loss
Diarrhoea
Vomiting
Bowel surgery
Pancreatic insufficiency
Inflammatory bowel disease
Losses from drains and wounds
```
68
Consequences of malnutrition
```
Impaired immunity
Impaired wound healing
Muscle mass loss
Respiratory function loss
Cardiac function loss
Impaired skin integrity
Impaired recovery from illness
Worsening prognosis
Low quality of life
Prolonged hospital stay
Greater healthcare needs
More admissions
```
69
What happens to insulin in chronic malnutrition? With refeeding? Phosphate levels
Insulin levels decreased - > increased
Normal in serum and low in cells -> move into cells which reduces serum electrolyte levels
70
What should you check before commencing refeeding?
U&E, LFT, ECG
71
Clinical features of refeeding syndrome?
CVS: arrhythmia, HT, CHF
GI: abdo pain, constipation, vomiting, anorexia
MUSC: weakness, myalgias, rhabdomyolysis, osteomalacia
RESP: SOB, ventilator dependence, respiratory muscle weakness
NEURO: weakness, paraesthesia, ataxia
METABOLIC: infections, thrombocytopaenia, haemolysis, anaemia
OTHER: ATN, Wernicke’s encephalopathy, liver failure
72
Blood results in refeeding syndrome
```
hypophosphataemia
hypokalaemia
hypomagnesaemia
hyperglycaemia
thiamine deficiency (erthryocyte transketolase or thiamine level)
trace elements deficiencies
```
73
Management of refeeding syndrome
Recognizing patients at risk
Replace electrolytes (P043-, K, Mg)
Monitor glucose and Na levels
Supportive care
Feeds, vitamins (B6,B12), folate
Refer to nutritional support team/dietician
74
What is syncope?
Transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery.
75
DDx of loss of consciousness by category?
```
Head (CNS / Psych)
Hypoxia
Epilepsy
Anxiety & hyperventilation
Dysfunctional brain stem
```
```
Heart
MI, ACS
PE
Aortic obstruction (AS, IHSS, myxmoma)
Arrhythmias
Long/short QT syndrome
```
Vessels
Vasovagal (emotional reaction)
Valsalva (micturition, cough, straining, sneeze)
Carotid sinus syncope
Situational (GI stimulation, post-exercise, post-prandial, weight lifting, wind instruments)
Autonomic dysfunction
Addison’s, diabetic vascular neuropathy
Drugs
CCB
B-Blocker
Antihypertensives
76
70% of syncope has previous sx, what could they be?
Prior faintness, dizziness, light headed
77
Red flag sx and why in syncope?
```
Exertional onset: aortic stenosis, cardiomyopathy, coronary artery disease
Chest pain: MI, PE
Dyspnoea: aortic stenosis, MI, PE
Low back pain: AAA rupture
Palpitations: arrhythmias
Severe headaches: cranial haemorrhage
Focal neurology
```
79
Sue is 86 and was brought in by relatives after being found trying to cook her tea in the washing machine
She did not appear to recognise them and kept asking where her mother was
Sue has recently been treated for a UTI last week
What further questions would you ask?
```
Premorbid personality
PMHx
Medications
Social circumstances
Past similar episodes
```
80
Old lady lives alone and functions well. Past Hx of vascular dementia and peripheral vascular disease. Stroke 4 years ago, recovered well. Fractures NOF after fall and is admitted. She is malnourished, incontinent of faeces.
Give 3 risk factors for pressure ulcers excluding age
How can you prevent pressure ulcers? (3 things)
Hip fracture was result of reduced bone density. Name 2 treatments that will improve bone health.
Immobility, malnutrition, dehydration, sensory impairment, obesity, urinary/feacal incontinence, reduced tissue perfusion
Mobile, repositioning, pressure redistributing mattress, barrier creams
Bisphosphonates, vitamin d and calcium supplements
