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COTE peer teaching Flashcards

1
Q

what things do you need to establish in the history if you suspect confusion

A

premorbid personality

past medical history

medications

social circumstances

any past similar episodes

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2
Q

differences between dementia and delirium

A
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3
Q

what causes delirium

A

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)

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4
Q

managing delirium

A

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

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5
Q

management of alzheimers

A

suppotive

acetylcholinesterase inhibitors such as donepezil

memantine

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6
Q

what are the 5 domains of the comprehensive geriatric assessment

A

physical health

mental health

social

function

environment

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7
Q

what are the complications of remaining on the floor for a long time following a fall

A

pressure ulcers

dehydration

rhabdomyolysis

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8
Q

how to investigate pressure ulcers

A
  • CRP
  • ESR
  • Swabs
  • Blood cultures
  • X-ray for bone involvement
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9
Q

management of pressure ulcers

A

antibiotics

wound dressing

pain relief

debridement if grade 3/4

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10
Q

what is osteoporosis

A

decreased bone mineral density due to imbalance between remodelling and resorption

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11
Q

risk factors for osteoporosis

A

smoking

early menopause

steroid use

being underweight

inactivity

alcohol use

age

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12
Q

how do you assess nutritional status

A

MUST screening tool

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13
Q

what does frax check for

A

10 yr fragility fracture risk

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14
Q

management of osteoporosis

A

bisphosphinates like alendronic acid and vitamin d and calcium supplementation if needed with adcal

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15
Q

biochemical features of refeeding syndrome

A
  • hypophosphataemia
  • hypokalaemia
  • thiamine deficiency
  • abnormal glucose metabolism
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16
Q

complications of refeeding syndrome

A

cardiac arrhythmias

coma

convulsions

cardiac failure

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17
Q

what are the 3 main features of parkinsons

A

resting tremor

bradykinesia

rigidity

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18
Q

differentiating features of a parkinsonian tremor

A

slow (pill rolling)

worse at rest

asymmetrical

reduced on distraction

reduced on movement

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19
Q

what is the usual pharmacological management of parkinsons

A

L-dopa given with a dopa decarboxylase inhibitor like carbidopa

combined drug like co careldopa

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20
Q

complications of l-dopa therapy

A

postural hypotension

confusion

hallucinations

dyskinesias

shortening duration of action of each dose

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21
Q

4 elements of pressure sore prevention

A
  1. barrier creams
  2. pressure redistrobution and friction reduction
  3. repositioning (every 6 hrs in normal risk, every 4 hrs in high risk)
  4. regular skin assessment
    • check for areas of pain and discomfort
    • skin integrity at pressure areas
    • colour changes
    • variations in heat, firmness and moisture
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22
Q

name 4 cardiac conditions that may cause an embolic CVA

A
  • atrial fibrillation
  • MI causing thrombus
  • infective endocarditis
  • aortic or mitral valve disease
  • patent foramen ovale
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23
Q

what colour does haemorrhage appear on CT

A

WHITE

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24
Q

Is parkinsons more common in men or women

A

twice as common in men

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25
Q

what is the mean age of diagnosis of parkinsons

A

65 years

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26
Q

management for parkinson’s

A
  • 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
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27
Q

what are the pros and cons of dopamine agonists and give an example

A
  • can be used in early disease
  • fewer motor complications than co-careldopa
    *
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28
Q

what are the pros and cons of MAO-B inhibitors?

give an example of one

A
  • it’s less effective in reduction of motor symptoms and improving ADLs but has fewer complications
  • an example is selegiline or rasagiline
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29
Q

how do MAO-B inhibitors work

A

inhibit dopamine breakdown

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30
Q

when to image in suspected stroke

A
  • 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.
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31
Q

acute ischaemic stroke initial assessment and treatment

A
  • 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
  • thrombectomy if occlusion demonstratef by CTA or MRA
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32
Q

causes of hyponatraemia

A
  • dilutional
    • heart failure
    • hypopoteinaemia
    • SIADH
    • fluid loss
    • NSAIDs (promote water retention)
    • oliguric renal failure
  • sodium loss
    • addison’s diseae
    • diarrhoea and vomiting
    • osmotic diuresis
      *
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33
Q

symptoms of hypocalcaemia

A

paraesthesia

tetany

carpopedal spasm (wrist flexion and fingers drawn together)

muscle cramps

seizures

prolonged QT

bronchospasm

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34
Q

symptoms of hypercalcaemia

A
  • 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
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35
Q

what MMSE score supports a diagnosis of dementia

A
  • <25 supports dementia
    • <10 is severe
    • 10-20 is moderate
    • 21-24 is mild
  • 25-27 is borderline
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36
Q

name 4 cognitive assessment tools for dementia

A
  • mini mental state examination (MMSE)
  • 6 item cognitive impairment test (6CIT)
  • abbreviatedm mental test score (AMT)
  • general practitioner assessment of cognition (GPCOG)
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37
Q

Types of dementia in order of prevalence

38
Q

alzheimers signs and symptoms

A
  • 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
39
Q

signs and symptoms of vascular dementia

A

step wise progression of focal neurological signs

there may also be evidence of vascular disease

40
Q

signs and symptoms of Lewy body dementia

A
  • fluctuating cognition
  • visual hallucinations
  • shuffling gait
  • increased tone
  • tremors
  • falls
  • disease course is generally an insidious onset that progresses with fluctuations
41
Q

signs and symptoms of frontotemporal dementia

A
  • 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
42
Q

pathology/imaging in alzheimers

A
  • generalised atrophy
43
Q

pathology/imaging of vascular dementia

A

strokes

lacunar infarcts

white matter lesions

vulnerable to cerebrovascular events

44
Q

pathology/imaging of lewy body dementia

A

generalised atrophy

lewy bodies in cortex and midbrain

45
Q

pathology/imaging of frontotemporal dementia

A

frontal and temporal atrophy

pick cells and pick bodies in cortex

46
Q

4 blood tests to exclude treatable causes of dementia

47
Q

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

48
Q

what is memantine and how does it work

49
Q

what does a comprehensive geritric assessment entail?

A
  1. Medical
    • issue list
    • co-morbid conditions and disease severity
    • medication review
    • nutritional status
  2. Mental health
    • cognition
    • mood and anxiety (depression screen)
    • fears
  3. functional capacity
    • activities of daily living
    • gait and balance
    • activity/exercise status
  4. social and environmental assessment
    • informal support from family and friends
    • care resources and eligibility
    • home safety and facilities
    • transport facilities
50
Q

what is the definition of delerium

51
Q

delirium risk factors

A

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

52
Q

signs and symptoms of delirium

53
Q

bedside tests for delirium

54
Q

Investigations for delirium

A

FBC

LFT

U&E

Sputum culture

folate B12

HbA1c

TFT

CXR, ECG urinalysis

55
Q

differentials of delirium

56
Q

reorientation strategies in delirium

A

easily visible, accurate clocks and calendars

continuity of care from carers and nursing staff

discourage napping and encourage bright light exposure in day time

57
Q

management for vascular dementia

58
Q

management for lewy body dementia

A

avoid anti-psychotics like haliperidol

use

59
Q

management for frontotemporal dementia

A

supportive

60
Q

what is a comprehensive geriatric assessment

A

an interdisciplinary diagnostic process to determine the medical psychological and functional capability of someone who is frail and old

61
Q

adverse effects of bisphosphonates

A
  • oesophageal: oesophagitis
  • osteonecrosis of the jaw
62
Q

how should bisphosphonates be taken

A
  • 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
63
Q

what are the meaning of the femoral neck T scores

A
  • -1 to +1: healthy
  • -2.5 to -1: osteopenia
  • >-2.5 osteoporosis
  • >-2.5 + fracture: severe osteoporosis
64
Q

diagnosing malnutrition

65
Q

what is the definition of malnutrition

A

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

66
Q

when is someone at risk of malnutrition

A
  • 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
67
Q

factors that would reduce caloric intake

68
Q

factors that increase caloric requirements

69
Q

factors increasing caloric loss

70
Q

consequences of malnutrition

A

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

71
Q

what are the clinical features of refeeding syndrome

A
  • 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
72
Q

what blood results would you see in refeeding syndrome

73
Q

management of refeeding syndrome

A

replace electrolytes

monitor glucose and Na levels

pabrinex

refer to dietician

74
Q

what is the definition of syncope

75
Q

what are the differentials for loss of consciousness

A
  • 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
76
Q

red flag symptoms of loss of consciousness

77
Q

what do patients need to be able to do to have capacity

78
Q

5 key points of the mental capacity act

A

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

79
Q

when trying to establish someone’s best interests what should you consider

A
  • 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
80
Q

what is the difference between advance refusals and requests in advance directives

A
  • 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
81
Q

under what conditions are advance refusals legally binding

A
  1. the person is an adult
  2. they were competent and fully informed when making the decision
  3. the decision is clearly applicable to the current circumstances
  4. there is no reason to believe that they have since changed their mind
82
Q

what is a DOL

83
Q

what is a lasting power of attorney

A

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

84
Q

four drugs for nausea and vomiting that you can put in a syringe driver

A

cyclizine, levomepromazine, haloperidol, metoclopramide

85
Q

three drugs that can be put in a syringe driver to treat respiratory secretions/bowel colic

A

hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.

86
Q

three drugs that can be put in a syringe driver to treat agitation/restlessness

A

midazolam, haloperidol, levomepromazine

87
Q

what is the preferred opioid for syringe driver administration

A

diamorphine

88
Q

8 drugs that cyclizine is incompatible with in a syringe driver

A

clonidine

dexamethasone

hyoscine butylbromide (occasional)

ketamine, ketorolac

metoclopramide

midazolam

octreotide

sodium chloride 0.9%

89
Q

what should you prescribe for agitation and confusion in the palliative care setting

A
  • first choice: haloperidol
  • other options: chlorpromazine, levomepromazine
90
Q

what is the drug for intractable hiccups in palliative care

A

chlorpromazine

91
Q

what are the 6 syndromes that cause nausea and vomiting in palliative care

A
  • 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

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