Elderly

Question 1

when is end-of-life according to NICE guidelines

Answer 1

last year of someone’s life

Question 2

what neurological changes occur when someone is dying

Answer 2

hypoactive delirium - reduced conscious, reduced response to verbal or visual stimuli
loss of pupillary reflex

changed breathing - Cheyennes stoke breathing (varying amplitude), apnoea (reduced O2)
fever

Question 3

what neuromuscular changes occur when someone is dying

Answer 3

unable to close eyes
unable to swallow
neck hyper-extended
grunting sound when breathing (death rattle), using mandibular muscles to breathe

Question 4

what cardiovascular changes occur when someone is dying

Answer 4

reduced blood pressure - can’t feel pulse
changed electrical activity of heart
reduced organ perfusion - skin mottling, low urine output

Question 5

what are the 2 different types of ageing

Answer 5

chronological - measurement of age in years, constant rate for all

biological - progressive loss of function causing a decrease in physiological ability to meet demands of increasing chronological age
no standardised markers, not fixed rate

Question 6

how do 2 people of the same age have different functional abilities

Answer 6

based on frailty
if old with high biological age = frail (when functionally dependent, so not Independent with ADL)

Question 7

what occurs in IADL + PADL disability

Answer 7

IADL (independent ADL) disability = physical frailty, sarcopenia
PADL (personal activities of daily living) disability = disabled, loss of independence

Question 8

how does inflammation cause biological ageing

Answer 8

with old age, immune response is mounted but not able to turn off
so there is low level inflammation (mild chronic elevation of IL6, TNF-a, CRP)
this low level inflammation can contribute to chronic diseases

Question 9

what are 2 premature ageing syndromes

Answer 9

Werner = autosomal dominant, defective WRN gene (encodes DNA - so somatic DNA damage), onset in teens
more common

Hutchinson-gilford progeria = autosomal recessive, gene defect in lamina-A (abnormal nuclear structure/function), onset at 2yrs

Question 10

summarise the different theories of ageing

Answer 10

1 - chronic, low-grade, sterile inflammation
2 - cellular senescence
3 - macromolecular dysfunction (accumulation of damaged DNA/proteins)
4 - stem-cell progenitor dysfunction
5 - non-genetic factors like nutrition/exercise affect rate of damage build-up

Question 11

what is frailty

Answer 11

when no longer IADL

age related decline in multiple physiological symptoms
causing ‘at risk’ state, so - vulnerable to minor stresses, disproportionate change in health status

Question 12

what abnormalities occur in __ system due to ageing
immune
endocrine
skeletal

Answer 12

immune - pro-inflammatory state as high IL6, CRP
endocrine - more catabolic state as high cortisol, but low GH/IGF1/sex hormones
skeletal - sarcopenia (loss of muscle mass/strength)

Question 13

what is sarcopenia

Answer 13

progressive generalised skeletal muscle disorder, causing accelerated loss of muscle mass/function

muscle mass peaks in 40s then declines
if more catabolic than anabolic = overall loss of skeletal muscle (low mass + low strength = muscle failure)

Question 14

does low muscle mass = sarcopenia (so frailty)

Answer 14

no sarcopenia (and frailty) = low muscle mass + low muscle strength

if low muscle mass alone = complex metabolic syndrome (malnutrition, cachexia)

Question 15

what is deconditioning syndrome

Answer 15

prolonged bed rest and immobility causes syndrome of physical/psychological/functional decline

can affect any age but greater effect on old people as more rapid/severe and changes are irreversible

Question 16

what are 2 frailty scoring systems

Answer 16

frailty phenotype by fried
- predefined set criteria with specific signs/symptoms
- clinical focus on sarcopenia and pre-disability
- categorical variable
- predetermined frailty cutoff

frailty index by rockall (clinical deficits out of 40, higher the score = more frail)
cut-off for frailty = 0.25 (upper threshold 0.67)
+ variable criteria according to pt comorbidities
+ multidimensional, including psychological/cognitive markers
+ continuous variable
- FI index too long (30 items) with varying cut-offs so unsure when to intervene

Question 17

who is the clinical frailty score used for

Answer 17

65yr+
compare current state with baseline status (2wk prior to illness)

Question 18

when is the clinical frailty score not useful

Answer 18

those with chronic disability

Question 19

what is dementia

Answer 19

clinical syndrome
significant deterioration in cognition, causing functional impairment (measured by ADL functioning)

Question 20

what are cognitive + behavioural symptoms of dementia

Answer 20

cognitive - poor memory, language difficulty, can’t plan or problem solve

behavioural - depressed/anxious, agitated, disinhibited, withdrawn

Question 21

what are the 4 types of dementia

Answer 21

alzheimer (most common - ApoE4 gene)
B-amyloid plaques, abnormal tau protein, neurofibrillary tangles
progressive impaired memory loss (STM affected, can’t process new info)

vascular
abnormal cerebral vasculature - cerebral small vessel disease
stepwise progression, focal signs (stroke)

DLB/PD
alpha-synuclein plaque, reduced DA release from SN
parkinonism features - bradykinesia, unilateral tremor, rigidity)
Lewy body - visual hallucinations of small animals/people

frontotemporal dementia
atrophy of frontal/temporal lobes
personality change, disturbed behaviour

CJ disease - prion proteins

Question 22

how is alzheimer diagnosed lab + imaging

Answer 22

B-amyloid deposition = low CSF AB, +ve amyloid on PET imaging

neuronal degeneration = high CSF tau, atrophy of medial temporal lobe, less FDG-PET uptake in temporoparietal cortices

Question 23

what protects against dementia

Answer 23

high cognitive reserve = preserved cognitive function in later life

associated with:
education, socioeconomic factors

Question 24

how is dementia investigated

Answer 24

clinical diagnosis with ICD10

cognitive assessment tools:
mini-cog at GP
AMTS, MMSE, ACE-III (addenbrokes cognitive assessment)
if ACE-III score 82-88 = mild cognitive impairment
if score 88+ = dementia

blood tests to exclude reversible cause:
FBC, UE, TFT, Ca, VitD, B12/B9, glucose

initial CT - tumour, stroke, chronic bleed
MRI gold standard - esp for prion disease CJD

Question 25

how are different types of dementia managed

Answer 25

alzheimer = AChE inhibitor (donepezil, rivastigmine)

vascular = stop smoking, diet, aspirin/clopidogrel

PD = L-dopa with carbidopa (but less effective long term and risks motor symptoms - dystonia)