Conditions

Question 1

Define dementia

Answer 1

Syndrome caused by a number of brain disorders which cause memory loss, decline in cognition and intellect and difficulties with activities in daily living

Question 2

Types of dementia

Answer 2

Alzheimer’s
Frontotemporal (Pick’s)
Lewi body dementia
Vascular

Question 3

Clinical features necessary for the diagnosis of dementia/ memory impairment

Answer 3

Global
Memory problems ( short/ long) term
Progressive
Decline in function

Question 4

Dementia and Driving. What is the the rules?

Answer 4

Legally obliged to inform the DVLA if driving

HGV licence is revoked

Question 5

Pathophysiology of alzheimer’s

Answer 5

Macroscopic: Global atrophy ( starting at media temporal lobe)
Microscopic: B-amyloid plaques and neurofibrillary tangles

Question 6

Clinical features and the time line in which they occur in Alzhemiers

Answer 6

EARLY

• Forgetting names
• Memory lapses
• Difficulties in finding words

MIDDLE

• Apraxia
• Impaired decision making skills
• Confusion

LONG

• Wandering
• Disorientation
• Apathy
• Behavioural problems

Question 7

Management of Alzhemiers

Answer 7

A) Donepezil (AChE inhibitor)

B) Memantine (NMDA receptor antagonist)

Question 8

Pathophysiology of vascular dementia

Answer 8

Macroscopic
Infracted grey and white matter

Group of syndromes of cognitive impairment caused by different mechanisms causing ischaemic haemorrhage secondary to CVD

Question 9

Clinical features of vascular dementia

Answer 9

Sudden onset
Step wise detonation
Focal neuro deficits
Difficulty with attention and concentration

Question 10

Pathophysiology of Lewy body dementia

Answer 10

Macroscopic: atrophy of the frontal, partial and occipital lobes
Lewi bodies in the occipo-partial cortex (intracellular aggregates of alpha-synuclein)

Question 11

Clinical features of levy body dementia

Answer 11

1. Parkinsonism
   - Tremor
   - Festinating gait
   - Rigidity
   - Bradykinesia
2. Visual hallucinations
3. Fluctuating levels of awareness and concentration

Question 12

Management of Lewy-body dementia

Answer 12

Rivastigmine (6-12mg OD)

Question 13

Pathophysiology of frontotemporal dementia

Answer 13

Abnormal protein ( tau and progranulin)
Macroscopic = atrophy of F + T lobes 
Microscopic = intracellular aggregation of tau 
(Pick's disease and picks bodies)

Question 14

Clinical features of frontotemporal dementia

Answer 14

Disinhibition
Personality change
Early memory preservation
Progressive aphasia

Question 15

List the possible causes of falls in the elderly

Answer 15

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)
Neurological: peripheral neuropathy, Parkinson’s
Hypoglycaemia
Visual impairment
Vertigo (e.g. BPV, meniere’s disease)
Poor environment (e.g. poor lighting, loose rugs)
Dementia

Question 16

Main features of parkinson

Answer 16

Tremor
Bradykinesia
Rigidity (lead-pipe; cogwheel)

Question 17

List differentiating features of parkinsonian tremor

Answer 17

Slow (pill-rolling)
Worse at rest
Asymmetrical
Reduced on distraction
Reduced on movement

Question 18

What class of drug is normally combined with L-dopa to prevent peripheral side-effects?

Answer 18

Dopa decarboxylase inhibitor (e.g. carbidopa or benserazide)

Question 19

Name 3 complications of L-dopa therapy.

Answer 19

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)

Remember DOPAMINE

Question 20

Pressure Ulcer Risk Factors

Name the scoring system

Answer 20

Age > 70
Being bedridden
Paralysis (may be partial)
Obesity
Urinary or bowel incontinence
Poor nutrition
Medical conditions that affect blood supply: diabetes, peripheral arterial disease, renal failure, heart failure

Waterlow scoring system

Question 21

Pressure Sore Prevention

Answer 21

Barrier creams

Pressure redistribution and friction reduction (e.g. special foam mattresses, heel support, cushions)

Repositioning (every 6 hrs in normal risk; every 4 hrs in high risk)

Regular skin assessment:

• Check for areas of pain or discomfort
• Skin integrity at pressure areas
• Colour changes
• Variations in heat, firmness and moisture (e.g. incontinence, oedema, dry, inflammed skin)

Question 22

Name 4 cardiac conditions that may cause an embolic CVA

Answer 22

Atrial fibrillation
MI causing mural thrombus
Infective endocarditis
Aortic or mitral valve disease
Patent foramen ovalee

Question 23

List 6 causes of delirium

Answer 23

Infection (commonly UTI and pneumonia)
Metabolic (hypoglycaemia, renal failure, liver failure, electrolyte imbalance e.g. hyponatriaemia, hypocalcaemia.)
Drugs: benzodiazepines, opiates, alcohol
Hypoxia
Nutritional deficiency (vitamin B12, thiamine)
MI
Intracranial lesion (incl. space-occupying, epilepsy, CVA, head injury)

Question 24

List 4 causes of hyponatriaemia.

Answer 24

135-145 = Normal 
DILUTION EFFECT
- Heart failure 
- Hypoproteinaemia 
- SIADH 
- Hypervolaemia/fluid excess
- NSAIDs
- Oliguric renal failure 

SODIUM LOSS

• Addison’s disease
• Diarrhoea & vomiting
• Osmotic diuresis
• Sever burns
• Diuretic stage of acute renal failure

If you replace Na too quickly central pontine mylinolysis

Question 25

Name 4 symptoms of hypocalcaemia

Answer 25

``` "SPASMODIC" Spasms ( caropedal) Periodical parasthesia Anxious Seizures Muscle tone increase Orientation reduced Dermatitis Impetigo hepaformis Chovesks sign +ve ```

Question 26

Name 4 symptoms of hypercalcaemia

Answer 26

Bone pain, fractures (hyperPTH or malignancy) Renal stones (renal colic); renal impairment (renal calcinosis); Polyuria, polydipsia, dehydration (nephrogenic diabetes insipidus) Drowsiness, delirium, muscle weakness, impaired cognition, depression, coma Nausea, vomiting, Constipation, abdominal pain, weight loss, anorexia HTN, shortened QT, arrhythmias

Question 27

What MMSE score supports a diagnosis of dementia?

Answer 27

MMSE <25 supports dementia. - 25-27 is borderline. - <10 severe; - 10-20 moderate; - 21-24 mild.

Question 28

What other cognitive assessment tools may be used?

Answer 28

Cognitive tests: - 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)

Question 29

List 4 blood tests you would do to exclude treatable causes of dementia

Answer 29

Blood tests: - Thyroid function tests - Syphilis serology (neurosyphilis) - Liver function tests (hepatic encephalopathy; alcoholism) - Vitamin B12, thiamine (B1) and folate levels

Question 30

What is Donepezil and what types of dementia can it be used to treat?

Answer 30

Donepezil is an Acetylcholinesterase inhibitor; used only in Alzheimer’s disease. (Others ACh-ase inhibitors: rivastigmine and galantamine) Alternative medication: Memantine, a N-methyl-D-aspartate (NMDA)-receptor antagonist which blocks glutamate. (Only in moderate to severe Alzheimer’s)

Question 31

List the different types of delirium

Answer 31

“Acute fluctuating syndrome of disturbed consciousness, attention, cognition and perception” Hyperactive  agitation, inappropriate behaviour, hallucinations Hypoactive  lethargy, reduced concentration

Question 32

List the risk factors for delirium

Answer 32

- Older age - Cognitive impairment - Frailty/multiple comorbidities - Significant injuries - Functional impairment - Hx of alcohol excess - Sensory impairment - Poor nutrition - Lack of stimulation - Terminal phase of illness

Question 33

Clinical features of delirium

Answer 33

Acute behavioural change (hours to days) Altered social behaviour Altered level of consciousness Falling and loss of appetite

Question 34

Differential diagnosis of delirium

Answer 34

Depression Dementia Mental illness Anxiety Thyroid disease Temporal lobe epilepsy Charles Bonnet syndrome

Question 35

How do you deem if some has capacity

Answer 35

Assessment of capacity - Understand the information relevant to the decision - Retain the information - Weigh up the information - Communicate the decision

Question 36

How long should a patient be on bisphosphonates following a #

Answer 36

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. If low risk/T score <2.5 stop and review in 2yrs

Question 37

List the patients who are at high risk of a future fractures

Answer 37

``` Glucocorticoid therapy Age >75 Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score ```

Question 38

How do bisphosphonates work?

Answer 38

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

Question 39

List 3 adverse effects of bisphosphonates.

Answer 39

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

Question 40

How are DEXA scan scores interpreted?

Answer 40

Femoral neck T-score of > -2.5. | If T score is -2.5 < X < -1 == osteopenia

Question 41

Define malnutrition

Answer 41

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.

Question 42

List the causes of malnutrition

Answer 42

Decreased nutrient intake (starvation) Increased nutrient requirements (sepsis or injury) Inability to utilise ingested nutrients (malabsorption)

Question 43

List the criteria for diagnosing malnutrition

Answer 43

BMI<18.5kg/m2 Unintentional weight loss >10% last 3-6 months Those at risk of malnutrition - Eaten little or nothing for > 5days - Poor absorptive capacity - High nutrient losses - Increased nutritional needs from causes such as catabolism

Question 44

List the factors increasing nutritional requirements

Answer 44

``` Acute infection/pyrexia Inflammatory condition Trauma Liver disease Wound healing Surgery Malignancy Chronic infection (e.g. HIV) ```

Question 45

List the consequences of malnutrition

Answer 45

``` Impaired immunity Impaired wound healing Muscle mass loss Respiratory function loss Cardiac function loss ```

Question 46

Explain the pathophysiology behind refeeding syndrome

Answer 46

Prolonged starvation followed by provision of nutritional supplementation Chronic malnutrition - Insulin levels decreased - Energy source switch to fats - Normal serum phosphate levels - Low intracellular phosphate levels Refeeding syndrome - Insulin increased - Movement of electrolytes into cell result in decreased serum electrolyte levels

Question 47

List the blood results in referring syndrome

Answer 47

``` Hypophosphataemia Hypokalaemia Hypomagnesaemia Hyperglycaemia Thiamine deficiency (erythryocyte transketolase or thiamine level) Trace elements deficiencies ```

Question 48

Management of referring syndrome

Answer 48

``` Replace electrolytes (P043-, K, Mg) Monitor glucose and Na levels ``` Supportive care Feeds, vitamins (B6,B12), folate Refer to nutritional support team/dietician

Question 49

List the diagnostic criteria for delirium

Answer 49

``` Clouding of consciousness Disorientation, impaired memory Incoherent speech Perceptual changes Psychomotor changes Sleep is affected ```