Conditions Flashcards
What is delirium?
- Acute deterioation in mental function
- arises over hours or days
- can last days-months
Delirium triggers?
- acute medical illness
- trauma
- drugs
Pathophysiology of delirium?
- direct toxic insult to brain
- stress response
Stress response releases ____ which may trigger delirium?
- cortisol
- prostaglandins
- cytokines
- cholinesterase activity
Risk factors for delirium?
- elderly
- pre-existing cognitive impairment
- post-operative
- sensory impairment
- previous delirium
- polypharmacy
Causes of delirium?
- infection
- polypharmacy
- constipation
- fluid overload
- hip fracture
- new environment
Symptoms of delirium?
- sudden
- short, fluctuating
- reversible
- agitation
- distorted illusions and hallucination
- inattention / decreased awareness
Types of delirium?
- hyperactive
- hypoactive
Screening for delirium?
- all aged > 65yrs screened
- 4AT screening score > 4 = may indicate delirium
What is the 4-AT score
- used to screen for delirium
- alertness
- AMT 4 (age, place, year, DOB)
- Attention
- acute change
What is the TIME bundle in delirium?
- Think about and treat
- Investigate and intervene
- Management plan
- Engage and Explore
Investigations for delirium?
- History (4 AT)
- Full exam + neuro examination
- basic obstruction + BG
- Medications review
Management of delirium?
- treat underlying cause
- management agitation
- TIME bundle
- Haloperidol (or lorazepam in Parkinson or Lewy body)
When should haloperidol not be used in the treatment of non-pharmacological responding delirium?
- when the patient has Parkinsons or Lewy body dementia
3 broad reasons for fall?
- motor co-ordination
- sensory inputs
- biomechanicals
Cautious gait risk
- decrease walking speed and step length
- increased time that both feet are on the ground
Name some drugs that contribute to falls
- antidepressants, antipsychotics
- antiarrhythmics
- benzodiazepines
- diuretics
- anticonvulsants
What is the falls risk associated with psychotropic drugs?
- doubles risk of falling
What is the falls risk associated with anti-hypertensives?
- a systolic bp < 110 increases risk of falls
- risk of orthostatic hypotension
What test can be performed to assess gait disturbances?
- Romberrg’s test
Commonest cause of syncope in the elderly?
- orthostatic hypotension
- differentials: arrhythmias, carotid sinus syndrome
What makes a diagnosis of orthostatic hypotension?
- lying and standing BP (0mins, 1 min, 3mins)
- drop in systolic > 20mmHg, drop in diastolic > 10mmHg
Causes of orthostatic hypotension?
- decreased autonomic buffering
- medications - alpha blockers
- volume depletion (diuretics or dehydration)
- peripheral neuropathy
- parkinsons/lewy body
Management of orthostatic hypotension?
- education
- fludrocortisone
Investigations into falls?
- history
- ECG
- BG
- Postural BP
- Timed get up and go
- Echocardiogram (if required)
- Brain CT (if required)
Requirements for a brain CT?
- GCS< 13
- GCS <15 after 2hrs
- new focal neurological deficit
- suspected open or decompressed fracture
- suspected base of skull fracture
- vomited > 2 times
- post-traumatic seizure
Explain the role of the carotid sinus?
- area in ICA with many baroreceptors for homeostasis
- sensed increase in pressure = peripheral vasodilation and drop in heart rate
What is carotid sinus syndrome
- abnormal activation of carotid sinus
- cerebral hypoperfusion = drop attack
Types of carotid sinus syndrome on carotid massage?
- cardio-inhibitory
- vasodepressor
- mixed
Explain cardio-inhibitory CSS
- Pause in heart rate > 3seconds
Explain vasodepressor CSS
- Drop in systolic BP > 50mmHg
If suspected CSS but no signs on carotid massage what investigation should be performed?
- tilt table test
Two main categories of stroke?
- haemorrhagic
- infarction (most common)
Causes of a haemorrhagic stroke
primary
- hypertension
- amyloid angiopathy
secondary
- arteriovenous malformations
- tumour
Causes of infarction haemorrhage?
- small vessel
- cardioembolic
- atheroembolic
Bamford classification of stroke?
- Total anterior circualtion
- partial anterior circulation
- lacunar
- posterior circulation
Symptoms of a partial anterior circulation syndrome?
- 2/3 TACS crietria
- hempiplegia
- homonomous hemianopia
- cortical signs
Symptoms of total anterior circulation stroke?
- hempiplegia
- homonomous hemianopia
- cortical signs
Symptoms of a posterior circulation stroke?
- cranial nerve palsies
- isolated homonomous hemianopia
- ipsilateral cerebellar deficits
Investigations for a stroke?
- carotid doppler
- ct angiogram
- MRI
What is associated with atrial fibrillation?
- cardioembolism
- infarction stroke
Why is there increased stroke risk in patent foramen ovale
- clots from venous circulation can enter the arterial circulation
Potential intervention for significant stenosis of the carotid artery?
- carotid endarterectomy
Ageing consequences on the bladder?
- decrease in bladder capacity
- decrease in urethral closure pressure
- increase in post void residual volume
- increase in detrusor overactivity
Transient causes of incontinence
(DIAPERS)
- Delirium
- Infection
- Atrophic vaginitis
- Psychological
- Pharmacological
- Endocrine
- Restricted mobility
- Stool impaction
Define urge incontinence?
- involuntary leakage associated with urgency
Define stress incontinence
- involuntary leakage on effort
Define mixed incontinence
- involuntary leakage associated with urgency and esertion
Define overflow incontinence
- leakage owing to bladder outflow obstruction resulting in large post-void volume
- constipation
Define functional incontinence
- incontinence resulting from an inability to reach the toilet in time
- poor mobility
- cognitive impairment
Taking a history of incontience should include
- voiding symptoms
- storage symptoms
- precipitants
- red flags
- bowel symptoms
- fluid intake
Red flags in incontinence?
- haematuria
- recurrent UTI
When should urinalysis be performed in incontience?
- only if result will change the management plan
Investigations for incontinence
- bladder diary
- bladder scanning
- urodynamic studies
Non-pharma management of incontinence
- lifestyle (caffeine, alcohol, weight)
- pelvic floor exercises
- bladder training
Pharmacological management of incontinence?
- tolterodine (antimuscarinic)
- solifenacin
- mirabegron
Consider what drug for nocturia?
- desmopressin
- check sodium
What can be prescribed for incontinence associated with atrophic vaginitis?
- vaginal oestrogens
