COTE peer teaching Flashcards
what things do you need to establish in the history if you suspect confusion
premorbid personality
past medical history
medications
social circumstances
any past similar episodes
differences between dementia and delirium
what causes delirium
Drug use
Electrolyteand physiological abnormalities
Lack of drug (withdrawal)
Infection
Reduced sensory input (blind, deaf, changing environment)
Intracranial problems (stroke, post ictal, meningitis, subdural)
Urinary retention and faecal impaction (or even just constipation)
Myocardial (MI, arrhythmia, HF)
managing delirium
treat the cause
manage the environment
soft lighting
clocks and calendars
sleep hygiene i.e. promote night time sleep
avoid multiple rooms/ward moves
minimise provocation
management of alzheimers
suppotive
acetylcholinesterase inhibitors such as donepezil
memantine
what are the 5 domains of the comprehensive geriatric assessment
physical health
mental health
social
function
environment
what are the complications of remaining on the floor for a long time following a fall
pressure ulcers
dehydration
rhabdomyolysis
how to investigate pressure ulcers
- CRP
- ESR
- Swabs
- Blood cultures
- X-ray for bone involvement
management of pressure ulcers
antibiotics
wound dressing
pain relief
debridement if grade 3/4
what is osteoporosis
decreased bone mineral density due to imbalance between remodelling and resorption
risk factors for osteoporosis
smoking
early menopause
steroid use
being underweight
inactivity
alcohol use
age
how do you assess nutritional status
MUST screening tool
what does frax check for
10 yr fragility fracture risk
management of osteoporosis
bisphosphinates like alendronic acid and vitamin d and calcium supplementation if needed with adcal
biochemical features of refeeding syndrome
- hypophosphataemia
- hypokalaemia
- thiamine deficiency
- abnormal glucose metabolism
complications of refeeding syndrome
cardiac arrhythmias
coma
convulsions
cardiac failure
what are the 3 main features of parkinsons
resting tremor
bradykinesia
rigidity
differentiating features of a parkinsonian tremor
slow (pill rolling)
worse at rest
asymmetrical
reduced on distraction
reduced on movement
what is the usual pharmacological management of parkinsons
L-dopa given with a dopa decarboxylase inhibitor like carbidopa
combined drug like co careldopa
complications of l-dopa therapy
postural hypotension
confusion
hallucinations
dyskinesias
shortening duration of action of each dose
4 elements of pressure sore prevention
- barrier creams
- pressure redistrobution and friction reduction
- repositioning (every 6 hrs in normal risk, every 4 hrs in high risk)
- regular skin assessment
- check for areas of pain and discomfort
- skin integrity at pressure areas
- colour changes
- variations in heat, firmness and moisture
name 4 cardiac conditions that may cause an embolic CVA
- atrial fibrillation
- MI causing thrombus
- infective endocarditis
- aortic or mitral valve disease
- patent foramen ovale
what colour does haemorrhage appear on CT
WHITE
Is parkinsons more common in men or women
twice as common in men
what is the mean age of diagnosis of parkinsons
65 years
management for parkinson’s
- at diagnosis if they have significant impact of motor symptoms of ADLs then treat with co-careldopa
- if they don’t have significant impact of motor symptoms of ADLs then treat with a choice of either dopamine agonists, co-careldopa or MAO-BI
- can also give anti-muscarinics which help with tremor and rigidity
- can also give amantidine which increases dopamine release and prevents reuptake in the synapses
what are the pros and cons of dopamine agonists and give an example
- can be used in early disease
- fewer motor complications than co-careldopa
*
what are the pros and cons of MAO-B inhibitors?
give an example of one
- it’s less effective in reduction of motor symptoms and improving ADLs but has fewer complications
- an example is selegiline or rasagiline
how do MAO-B inhibitors work
inhibit dopamine breakdown
when to image in suspected stroke
- CT within one hour if
- indications for thrombolysis or thrombectomy
- on anticoagulation
- known bleeder
- GCS<13
- severe headache at onset of stroke symptoms
- CT as soon as possible and within 24 hours of symptom onset in everyone with suspected acute stroke without indications for immediate brain imaging.
acute ischaemic stroke initial assessment and treatment
- thrombolysis with alteplase if
- within 4.5 hours of onset of stroke symptoms
- intracranial haemorrhage has been excluded
- for everyone presenting with acute stroke who has had haemorrhage excluded by CT
- give 300mg aspirin asap and continue for two weeks
- give PPI
- after 2 weeks start definitive long-term anti-thrombotic treatment
- give 300mg aspirin asap and continue for two weeks
- thrombectomy if occlusion demonstratef by CTA or MRA
causes of hyponatraemia
- dilutional
- heart failure
- hypopoteinaemia
- SIADH
- fluid loss
- NSAIDs (promote water retention)
- oliguric renal failure
- sodium loss
- addison’s diseae
- diarrhoea and vomiting
- osmotic diuresis
*
symptoms of hypocalcaemia
paraesthesia
tetany
carpopedal spasm (wrist flexion and fingers drawn together)
muscle cramps
seizures
prolonged QT
bronchospasm
symptoms of hypercalcaemia
- bones stones moans and groans
- bone pain and fractures
- renal stones
- mental moans
- drowsiness
- delerium
- coma
- muscle weakness
- impaired cognition
- depression
- tummy groans
- nausea
- weight loss
- vomiting
- anorexia
- constipation
- abdo pain
- also HTN shortened QT arrhythmias
what MMSE score supports a diagnosis of dementia
- <25 supports dementia
- <10 is severe
- 10-20 is moderate
- 21-24 is mild
- 25-27 is borderline
name 4 cognitive assessment tools for dementia
- mini mental state examination (MMSE)
- 6 item cognitive impairment test (6CIT)
- abbreviatedm mental test score (AMT)
- general practitioner assessment of cognition (GPCOG)
Types of dementia in order of prevalence
alzheimers signs and symptoms
- gradual progressive onset
- memory loss
- language deficits
- impaired visuospatial skills
- normal gait and neuro exam in early disease
- later there are behavioural symptoms such as aggression
signs and symptoms of vascular dementia
step wise progression of focal neurological signs
there may also be evidence of vascular disease
signs and symptoms of Lewy body dementia
- fluctuating cognition
- visual hallucinations
- shuffling gait
- increased tone
- tremors
- falls
- disease course is generally an insidious onset that progresses with fluctuations
signs and symptoms of frontotemporal dementia
- disinhibition
- socially inappropriate behaviour
- poor judgement
- apathy
- decreased motivation
- poor executive function
- disease course is an insidious onset in the 50s-60s with rapid progression
pathology/imaging in alzheimers
- generalised atrophy
pathology/imaging of vascular dementia
strokes
lacunar infarcts
white matter lesions
vulnerable to cerebrovascular events
pathology/imaging of lewy body dementia
generalised atrophy
lewy bodies in cortex and midbrain
pathology/imaging of frontotemporal dementia
frontal and temporal atrophy
pick cells and pick bodies in cortex
4 blood tests to exclude treatable causes of dementia
what is donepezil and what types of dementia can it be used to treat?
what is memantine and how does it work
what does a comprehensive geritric assessment entail?
- Medical
- issue list
- co-morbid conditions and disease severity
- medication review
- nutritional status
- Mental health
- cognition
- mood and anxiety (depression screen)
- fears
- functional capacity
- activities of daily living
- gait and balance
- activity/exercise status
- social and environmental assessment
- informal support from family and friends
- care resources and eligibility
- home safety and facilities
- transport facilities
what is the definition of delerium
delirium risk factors
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
signs and symptoms of delirium
bedside tests for delirium
Investigations for delirium
FBC
LFT
U&E
Sputum culture
folate B12
HbA1c
TFT
CXR, ECG urinalysis
differentials of delirium
reorientation strategies in delirium
easily visible, accurate clocks and calendars
continuity of care from carers and nursing staff
discourage napping and encourage bright light exposure in day time
management for vascular dementia
management for lewy body dementia
avoid anti-psychotics like haliperidol
use
management for frontotemporal dementia
supportive
what is a comprehensive geriatric assessment
an interdisciplinary diagnostic process to determine the medical psychological and functional capability of someone who is frail and old
adverse effects of bisphosphonates
- oesophageal: oesophagitis
- osteonecrosis of the jaw
how should bisphosphonates be taken
- sitting or standing
- at least 30 minutes before breakfast
- with a full glass of water
- stand or sit upright for a full 30 minutes following
what are the meaning of the femoral neck T scores
- -1 to +1: healthy
- -2.5 to -1: osteopenia
- >-2.5 osteoporosis
- >-2.5 + fracture: severe osteoporosis
diagnosing malnutrition
what is the definition of malnutrition
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
when is someone at risk of malnutrition
- eaten little or nothing for >5 days (or likey to do so)
- poor absorptive capacity
- high nutrient losses
- increased nutritional needs from causes such as catabolism
factors that would reduce caloric intake
factors that increase caloric requirements
factors increasing caloric loss
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
more hospital admissions and greater healthcare needs
what are the clinical features of refeeding syndrome
- CVS: arrhythmia
- GI: abdo pain, constipation, vomiting, anorexxia
- MUSC: weakness, myalgia, rhabdomyolysis, osteomalacia
- RESP: SOB, respiratory muscle weakness, ventilator dependence
- NEURO: weakness, paraesthesia, ataxia
- METABOLIC: infections, thrombocytopaenia, haemolysis, anaemia
what blood results would you see in refeeding syndrome
management of refeeding syndrome
replace electrolytes
monitor glucose and Na levels
pabrinex
refer to dietician
what is the definition of syncope
what are the differentials for loss of consciousness
- head heart vessels
- head
- hypoxia
- epilepsy
- anxiety and hyperventilation
- heart
- ACS
- PE
- Aortic obstruction
- arrhythmias
- long/short QT syndrome
- brugada syndrome
- cardiomyopathy
- vessels
- vasovagal
- valsalva
- carotid sinus syncope
- low systemic vascular resistance
- drugs like CCBs, beta blockers, anti-hypertensives
red flag symptoms of loss of consciousness
what do patients need to be able to do to have capacity
5 key points of the mental capacity act
assume capacity
maximise decision making capacity - support given to reach decision
freedom to make seemingly unwise decisions
best interests - all decisions made on behalf of a person should be in their best interests
least restrictive option - when making choices on behalf of another person, the choice that achieves the necessary goal and interferes least with that person’s life must be chosen
when trying to establish someone’s best interests what should you consider
- whether someone is likely to regain capacity and can the decision wait until then
- how to encourage and optimise the participation of the person in the decision
- the past and present wishes, feelings, beliefs, values of the person
- the views of people relevant to the person
what is the difference between advance refusals and requests in advance directives
- advance requests do not have the same legal binding status as advance refusals but they should be considerd when assessing best interest of the patient
- i.e. if it was their wish to be kept alive with artificial nutrition and hydration
under what conditions are advance refusals legally binding
- the person is an adult
- they were competent and fully informed when making the decision
- the decision is clearly applicable to the current circumstances
- there is no reason to believe that they have since changed their mind
what is a DOL
what is a lasting power of attorney
a document in which a person can nominate someone else to make cerrtain decisions on their behalf
for example decisions about finances, health, personal welfare etc
to be valid it needs to be registered with the office of public guardian
four drugs for nausea and vomiting that you can put in a syringe driver
cyclizine, levomepromazine, haloperidol, metoclopramide
three drugs that can be put in a syringe driver to treat respiratory secretions/bowel colic
hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.
three drugs that can be put in a syringe driver to treat agitation/restlessness
midazolam, haloperidol, levomepromazine
what is the preferred opioid for syringe driver administration
diamorphine
8 drugs that cyclizine is incompatible with in a syringe driver
clonidine
dexamethasone
hyoscine butylbromide (occasional)
ketamine, ketorolac
metoclopramide
midazolam
octreotide
sodium chloride 0.9%
what should you prescribe for agitation and confusion in the palliative care setting
- first choice: haloperidol
- other options: chlorpromazine, levomepromazine
what is the drug for intractable hiccups in palliative care
chlorpromazine
what are the 6 syndromes that cause nausea and vomiting in palliative care
- Reduced gastric motility
- May be opioid related
- Related to serotonin (5HT4) and dopamine (D2) receptors
- Chemically mediated
- Secondary to hypercalcaemia, opioids, or chemotherapy
- Visceral/serosal
- Due to constipation
- Oral candidiasis
- Raised intra-cranial pressure
- Usually in context of cerebral metastases
- Vestibular
- Related to activation of acetylcholine and histamine (H1) receptors
- Most frequently in palliative care is opioid related
- Can be motion related, or due to base of skull tumours
- Cortical
- May be due to anxiety, pain, fear and/or anticipatory nausea
- Related to GABA and histamine (H1) receptors in the cerebral cortex
