Elderly Medicine Flashcards
What is Meig’s syndrome?
Is the triad of:
- Ascites
- Pleural effusion
- Benign ovarian tumor (fibroma)
What are the symptoms of Meigs syndrome?
- Fatigue
- Dyspnoea (initially on exertion).
- Pelvic pain or bloating, constipation.
- Swollen abdomen with associated weight gain or weight loss.
- Non-productive cough.
- Amenorrhoea or irregular menstruation.
How do you diagnose Meigs syndrome?
Reduction in lung capacity
CA125 will be raised
What is the management of Meigs syndrome?
Surgical removal of the tumour
Correction of plural effusion
What is progressive supranuclear palsy?
Aka Steele-Richardson-Olszewski syndrome
A ‘Parkinson Plus’ syndrome
What are the symptoms of progressive supranuclear palsy?
- Impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
- Parkinsonism
- Falls
- Slurring of speech
- Cognitive impairment
What is the management for progressive supranucelar palsy?
Poor response to L-dopa
What are the grades of pressure sores?
-
Grade 1
Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness -
Grade 2
Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister -
Grade 3
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. -
Grade 4
Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss
What is part of the acute confusion screen?
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
What are precipitating factors to acute confusion state?
- Age > 65 years
- Background of dementia
- Significant injury e.g. hip fracture
- Frailty or multimorbidity
- Polypharmacy
What are normally the preciptating events to acute confusional state?
- Infection: particularly urinary tract infections
- Metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
- Change of environment
- Any significant cardiovascular, respiratory, neurological or endocrine condition
- Severe pain
- Alcohol withdrawal
- Constipation
What are the symptoms of acute confusional state?
- Memory disturbances (loss of short term > long term)
- May be very agitated or withdrawn
- Disorientation
- Mood change
- Visual hallucinations
- Disturbed sleep cycle
- Poor attention
What is the management of acute confusional state?
Treatment of the underlying cause
Modification of the environment
Haloperidol 0.5 mg as the first-line sedative
Name some medications that cause postural hypotension?
- ACE-inhibitors
- Beta-blockers
- Diuretics
- Antidepressants
- Anticholinergic medications
- Nitrates
- L-Dopa
Name some medications associated with falls due to other mechanisms?
- Benzodiazepines
- Antipsychotics
- Opiates
- Anticonvulsants
- Codeine
- Digoxin
- Other sedative agents
What is the definition of polypharmacy?
A single patient taking 5 or more medications daily
What drugs should be avoided in Parkinson’s patients?
Atypical antipsychotics
What drugs should be avoided in Lewy body dementia?
Antipsychotics
Name a acetycholinesterase inhibitor?
Donepezil
Rivastigmine
Galantamine
Name a NMDA antagonist?
Memantine
When are oral antibiotics used on a pressure ulcer?
Only when there are signs of infection
What is seen on an MRI for Alzeimer’s disease?
Widespread cerebral atrophy mainly involivng the cortex and hippocampus
What does raised intracranial pressure show on CT?
Effacement of the cerebral ventricle and loss of grey-white matter differentation
What is seen on CT with frontotemporal dementia?
Frontal lobe atrophy
What does a focal hyperdense lesion in the occipital region mean on CT?
Characteristic of a brain tumour within the occipital lesion
What are the features of Lewy body dementia?
-
Progressive cognitive impairment
- in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
- cognition may be fluctuating, in contrast to other forms of dementia
- usually develops before parkinsonism
- Parkinsonism
- Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
What are the investigations for Lewy body dementia?
- Usually clinical
- Single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%
What is the management of Lewy body dementia?
- Both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details
- Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent
What is the mechanism of haloperidol?
Dopamine antagonist
What medication may be given instead of halopeidol for parkinson’s patients?
Lorazepam
What are the key features of a history for lewy body dementia?
- Flutuating cognitive function in contrast to other forms of dementia
- Visual hallucinations
- Parkinsonism
Which class of medications should be withdrawn in patients with dementia?
Why?
Tricylic antidepressants
Due to worsening of cognitive impairment
What are the first line drugs for alzheimer’s?
- Acetylcholinesterase inhibitors
- Donepezil
- Galantamine
- Rivastigmine
What is the second line drug for alzheimer’s?
Memantine
What medication causes blurry vision, nausea, and falls?
Digoxin
What factors favour frontotemporal dementia over bipolar affective disorder?
- Presents later in life
- Social disinhibition
- Family history
When is Lewy body dementia favoured over parkinson’s?
- Cognitive symptoms started before motor
