Flash1 Flashcards
Which of the following conditions is the major contraindication for an older person to be involved in an exercise programme?
A. Alzheimer’s dementia.
B. Unstable angina pectoris.
C. Atrial fibrillation.
D. Stroke.
E. Chronic obstructive pulmonary disease.
Answer: B
Discussion:
Really shouldn’t have to go through this one… Alzheimer’s – exercise programs can be useful from a cognitive point of view. AF – probably shouldn’t run if you are unstable, but can do exercise. Stroke – definitely useful. COPD – pulmonary rehab is recommended if FEV
Which of the following is the main risk factor for the development of delirium in older people?
A. Surgery.
B. Dementia.
C. Polypharmacy.
D. Indwelling catheter.
E. Sensory impairment.
Answer: B
Discussion:
The two most important risks for delirium are older age and baseline cognitive dysfunction – up to 50% of those with some cognitive impairment or over age 65 get some delirium.
Other factors:
• sensory deprivation (eh? Can’t hear you?)
• poor mobility
• malnutrition
• underlying medical/neurological illness In hospital risks:
• IDC • Physical restraint
• Sleep/sensory deprivation
• Adding 3 or more medications Surgical/anaesthetic factors:
• cardiopulmonary bypass
• poor pain control postoperatively
As a side note, delirium in ICU in older patients is over 70%! – and is associated with a high mortality rate.
Remember the CAM rule?
- Acute onset and fluctutating course
- Inattention
- Disorganised thinking
- Altered level of consciousness
Need 1 and 2 and either 3 or 4
An 82-year-old female complains of a decline in short-term memory, specifically difficulty remembering some names and telephone numbers. She lives alone in her own home and has been independent in all activities of daily living and instrumental activities of daily living, since the death of her husband one year previously. Her mini-mental state examination (MMSE) score is 27 out of 30, with short-term recall of only one out of three items.
The most likely diagnosis is:
A. early vascular dementia.
B. early Alzheimer’s dementia.
C. mild cognitive impairment.
D. grief reaction.
E. normal aging.
Answer: C
Discussion:
At age 85, the average person can recall about half the number of items on a list that they could at age 18. Mild cognitive impairment is defined as a cognitive problem that has begun to subtly interfere with daily activities. AD: • Most begin with memory loss • Can also have difficulty with driving or shopping • Difficulty finding words FTD: • Change in personality • Disinhibition • Food obsession • Apathy • Loss of executive function Progressive abnormalities in speech DLB • Early visual hallucinations • Parkinsonism • Delirium • REM sleep disorder • Capgras’ syndrome Vascular: Sudden stroke with irregular progression -> multi infarct CJD: • Rapid progression • Myoclonus • Motor rigidity Most common causes of reversible dementia are depression, hydrocephalus, and alcohol dependence – about 1 in 5 reversible.
Which of the following drugs is least likely to exacerbate urinary retention in an elderly man with benign prostate hypertrophy?
A. Chlorpromazine.
B. Citalopram.
C. Amitriptyline.
D. Olanzapine.
E. Promethazine.
Answer: C
Discussion:
How do these drugs work? This question relies on our knowledge of the anticholinergic effects/adverse effects of these drugs.
Chlorpromazine is a phenothiazine, which has antipsychotic actions (basis for which are not fully understood). Acts as a dopamine inhibitor, and also produces alpha adrenergic blockade (which is why you have to watch for hypotension). Also pushes up sugar and cholesterol. Commonly causes urinary retention.
Citalopram is a selective serotonin reuptake inhibitor, and is in fact one of the most selective – ‘no or minimal effects’ on noradrenaline, dopamine or GABA. Order of selectivity goes:
escitalopram -> citalopram -> sertraline -> paroxetine -> fluvoxaminae -> fluoxetine
Very low affinity for cholinergic (or any other) receptors, on in vivo and in vitro tests. Uncommonly causes urinary retention.
Amitriptyline’s actions are unclear – it inhibits the uptake of noradrenaline and serotonin, which prolongs neuronal activity. Has significant anticholinergic properties. MEtabolised in the liver and converted to nortriptyline, the active metabolite, which has a half life of about 26 hours.
Olanzapine, the atypical antipsychotic. A favoured drug among the Caulfieldians. Has a broad range of effects on receptors, including serotonin, dopamine (more serotonin than dopamine), cholinergic, alpha adrenergic and histamine. Metabolised in the liver with a metabolite that doesn’t cross the blood brain barrier. Half life is about 33 hours, or in the elderly, about 51 hours. Smoking increases the clearance of olanzapine as it induces CYP1A2. Commonly causes orthostatic hypotension, and urinary incontinence. Very rarely (
Promethazine is a phenothiazine derivative, basically acting as a long acting antihistamine but does have some anticholinergic and anti-serotonin effects. Also has marked hypnotic and tranquiliser effect (as many mothers with crying children probably know). Does cause urinary retention.
In the Australasian population over the age of 65 years, the most frequent cause of disability (defined as needing assistance or experiencing difficulties with self-care, mobility or communication) is:
A. dementia.
B. arthritis.
C. diabetes.
D. heart failure.
E. chronic obstructive pulmonary disease (COPD).
Answer: B
Discussion:
> The filename is crap and is just there to express my disillusionment.
> The below is from the Australian Bureau of Statistics, who don’t really know how to present their data well.
> Well done Census.
> Diseases of the musculoskeletal system and connective tissue were identified as the most prevalent group of main disabling conditions in Australia in both 2003 and 2009 (Graph). However, the overall rate decreased significantly from 6.8% in 2003, to 6.5% in 2009. The largest falls were in the 18-44 year age group (down 0.8%) and the 45-64 year age group (down 1.6%).
> In 2003, 1.8% of the Australian population reported diseases of the circulatory system as being their main disabling condition, compared to 1.4% in 2009.
- There was a statistically significant reduction in reporting of heart disease as the main disabling condition in 45-64 year olds from 1.1% in 2003 to 0.6% in 2009, and in the 65 years and over age group from 3.8% to 3.4% (Graph 13).
> The prevalence of stroke as the main disabling condition also decreased overall, from 0.4% in 2003 to 0.3% in 2009. Although the incidence of stroke in 45-64 year olds increased from 0.2% in 2003 to 0.3% in 2009, this was offset by a decrease in the 65 years and over age group, from 2.1% to 1.3% (Graph 14).
> Unlike heart disease and stroke, prevalence rates of hypertension as the main disabling condition remained similar between 2003 and 2009, at 0.4% in 2003 and 2009 (Graph 15).
> Diseases of the respiratory system include asthma, emphysema, bronchitis, chronic airways obstruction and other respiratory disease most often characterised by shortness of breath and restriction in oxygen intake.
> In 2003, 1.2% of people in Australia reported a disease of the respiratory system as being their main disabling condition, compared to 0.9% in 2009. The main contributor to the decrease in diseases of the respiratory system between 2003 and 2009 was asthma.
> Diabetes can result in many long-term health conditions, including heart disease, stroke, kidney failure, blindness and lower limb amputation. It is a chronic condition in which blood glucose levels become too high due to the body producing little or no insulin, or not using insulin properly. Chronic diseases such as diabetes represent a major part of the burden of disease in Australia, and may be prevented or delayed by lifestyle interventions.
> Mental health problems and mental illness are among the greatest causes of disability, diminished quality of life, and reduced productivity. People affected by mental health problems often have high levels of morbidity and mortality, experiencing poorer general health and higher rates of death from a range of causes, including suicide. Just how high I’m not sure, but less than arthritis in old people.
The life expectancy (in years) for the average Caucasian Australasian male aged 65 is:
A. 5.
B. 7.
C. 10.
D. 15.
E. 25.
Answer: D
Discussion:
Life expectancy is calculated using a mathematical tool called a ‘life table’. These are constructed by taking death rates from the population in question (such as Australian males in 2006) and applying them to a hypothetical cohort of persons. The life table is then able to provide probabilities concerning the likelihood of someone in this hypothetical population dying or surviving before their next birthday. Life expectancy can be provided for any age in the life table, by summing the number of person years (the total number of years lived by all persons in the life table) and dividing this by the number of persons still alive in the life table.
A common measure used to summarise this is ‘health adjusted life expectancy’ (HALE). This is an estimate of the number of healthy years (free from disability or disease) that a person born in a particular year can expect to live based on current trends in deaths and disease patterns. The average number of years spent in unhealthy states is subtracted from the overall life expectancy, taking into account the relative severity of such states.
The estimated HALE for Australia in 2003 was 70.6 years for males and 75.2 years for females.
s
The methodology used to calculate this table has changed since 1995. Data on population and deaths averaged over 3 years are now used to minimise year to year statistical variations.
Sources: ABS Cat. No. 3302.0; ABS Cat. No. 3105.0.65.001
Based on the latest mortality rates, a boy born in 2006 would be expected to live to 78.7 years on average, while a girl would be expected to live to 83.5 years. However, a man and woman aged 25 in 2006 would be expected to live to ages 79.7 and 84.2 years respectively. This shows that once people survive through childhood, the chance of dying as a young adult is very low and hence life expectancy increases.
For which of the following conditions is walking exercise most efficacious compared with weightlifting?
A. Insulin resistance.
B. Depression.
C. Osteoarthritis of the knee.
D. Vascular claudication.
E. Falls.
Answer: D
Discussion:
Stroke
Therapeutic exercise has been shown in several studies to benefit poststroke patients.[7] In one study, it improved function and the quality of life in patients with a subacute stroke, increasing their endurance, balance, and mobility.[8]In a similar study in the same patient population, therapeutic exercise improved depressive symptoms. A large systematic review revealed that progressive resistance exercise can improve strength and activity in acute and chronic stroke patients without increasing spasticity.[9]
Multiple sclerosis
Several studies have shown that endurance and resistance training can reduce fatigue in patients with multiple sclerosis (MS).[10] Quality of life has been improved with endurance training. Studies have also shown improvements in VO2 max and strength as a result of endurance and resistance training, respectively.[11]
Some MS patients’ symptoms worsen in response to higher ambient temperatures. Interval training and/or precooling prior to the exercise session may be preferable for them.
Diabetes mellitus
Exercise is important in diabetes prevention and management. Exercise has been shown to decrease glycosylated hemoglobin, blood pressure, and diabetic medication doses in people with type 2 diabetes.
Exercise improves insulin sensitivity by acting directly on the muscle, causing autophosphorylation, glucose transporter 4 (GLUT-4) content, and glucose transport-phosphorylation to increase. Exercise reduces visceral obesity, which decreases free fatty acids. It also increases insulin-stimulated limb blood flow. Resistance training leads to muscular hypertrophy, which improves glycemic control by increasing the storage size for glucose disposal.
Exercise has also been shown to slow the development of diabetic peripheral neuropathy.[12] The exact mechanism of this is unknown, but the authors of the study do propose some possible explanations. Exercise may cause cellular changes that result in increased endoneurial blood flow and greater oxygen delivery. Another mechanism could be an exercise-induced increase in the concentration of Na+/K+ –adenosine triphosphatase (ATPase) pumps. K-channel openers have been shown in experiments to improve nerve perfusion and function in patients with diabetic neuropathy.
Osteoporosis
Multiple trials in postmenopausal women have shown improvements in bone-mineral density as a result of resistance training. They have also shown improvements in strength and muscle mass, which can help with functional activities.[13, 14, 15, 16, 17, 18, 19]
The exercise routines can be simple and should have no jarring motions or sudden changes in direction, which may result in a fall. Progression should occur gradually, with sets added before weight is increased.
Parkinson disease
Several studies have shown that therapeutic exercise can increase function and quality of life in people with Parkinson disease. Researchers found that an exercise program consisting of flexibility, endurance, and resistance training improved patients’ perceptions of quality of life by increasing physical activity and social interaction.[20] Another study demonstrated that high-intensity resistance training could result in muscular hypertrophy; more important, it led to improvements in stair descent times and 6-minute walk distances.[21] High-intensity resistance training has also been shown to increase balance.[22] In another study, endurance training improved movement initiation times and increased VO2 max.
Neuromuscular disease
Strength can be increased in children with Duchenne muscular dystrophy and in adults with slowly progressive neuromuscular disease. The exercise needs to begin when the muscle groups have significantly more than simply antigravity strength. Exercising muscles that do not have antigravity strength may cause them to become weaker. The exercises need to be performed on a routine basis because any discontinuation will result in a rapid decrease in the strength gained. They also need to be performed at a submaximal level. There is no clinical evidence that exercising muscles in individuals with neuromuscular disease will result in long-term improvements.
There have been only a few studies pertaining to endurance training and neuromuscular disease. Most of these have shown a positive effect from the training. Individuals have had variable responses to the training, probably owing to their level of conditioning at the time their study participation began and because of the effects of individual diseases. The cardiopulmonary adaptations to submaximal training in persons with neuromuscular disease are similar qualitatively to those in individuals without this type of illness. Short-term adaptations may be made, but the long-term effect of the training is unknown and may be limited by loss of muscle mass.
Balance disorders
Therapeutic exercise, including resistance training, flexibility training, multicomponent exercise, and others including tai chi, for the treatment of balance disorders and balance confidence has been studied extensively in older adults.[23, 24, 25, 26, 27, 28] Resistance and endurance training programs incorporating jumping and mini trampoline exercise have also been shown to improve balance in elderly persons.[29, 30] In a meta-analysis of randomized controlled trials on exercise and balance confidence in adults aged 60 years and older without a neurological condition conducted in 2009 demonstrated low significant effects for exercise and multifactorial interventions and medium significant effects for tai chi.[31]
Recumbent and convalescing patients
Recumbent and convalescing patients require maintenance by means of AAROM or PROM exercises, aided or performed by a therapist, to preserve full joint mobility and prevent joint stiffness and muscle contractures.
During or immediately after a patient’s hospital stay, the patient should be referred to a physical training program; otherwise, an individual therapeutic regimen appropriate to the patient’s physical capacity should be designed in order to maintain and, whenever possible, improve his or her level of physical fitness. Thus, physical fitness maintenance or training can be performed either by means of an individual program carried out by the patient at home or by participation in a group training program.
Which of the following interventions is most likely to prevent falls in an 80-year-old community-dwelling woman?
A. Home hazard reduction.
B. Balance and strength training.
C. Antihypertensive medication reduction.
D. Walking daily.
E. A falls education program.
Answer: B
Discussion:
Edited from le Cochrane
Background
Approximately 30% of people over 65 years of age living in the community fall each year.
Objectives
To assess the effects of interventions to reduce the incidence of falls in older people living in the community.
Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).
Selection criteria
Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.
Main results
We included 111 trials (55,303 participants).
Reduced rate of falls (number of falls)/risk of falling (number of fallers)
> Multiple-component group exercise reduced (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97)
> Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82)
> Individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).
> Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.
> An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).
> A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).
> Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75).
> First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).
Did not:
> Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels.
> Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03; RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling.
> Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling.
> There is some evidence that falls prevention strategies can be cost saving.
Authors’ conclusions
Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.
An 82-year-old man is admitted with pneumonia and fever. Which one of the following is most suggestive of the diagnosis of delirium?
A. Inability to stay focused on questions being asked.
B. Worsening behaviour at night.
C. Angry outbursts and claims that the staff are trying to harm him.
D. Mini-Mental Status Examination score of 18/30.
E. Depressed affect.
Answer: A
Discussion:
- DSM-IV-TR diagnostic criteria for delirium[13]
- Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention.
- Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia.
- The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
- Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.
QUESTION 82
An 82-year-old woman presents to the emergency department with an acute crush fracture of the thoracic spine. She is discharged home with pain relief.
Which of the following factors is the best predictor of readmission in the next month?
A. Depressed mood.
B. Urinary incontinence.
C. Living alone.
D. Advanced age.
E. Functional impairment.
Answer E
Which clinical feature of delirium is most useful for differentiating it from dementia?
A. Inability to count backwards from 30
B. Failure to recall 3 items after a 3-minute delay
C. Disorientation in time and place but not person
D. Paranoid delusions
E. Sleep-wake disturbance with nocturnal wandering
Answer A- Inability to count backwards from 30
Discussion
Delerium
Definition (DSM-IV):
- 1. Inattention: Reduced ability to focus, sustain, or shift attention
- 2. A change in 1) cognition and 2) level of consciousness: Disturbance of consciousness; and development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
- 3. Acute onset, fluctuating: The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
- 4. Causal factors present: There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect.
Additional features that may accompany delirium and confusion include the following:
- 5. Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased sympathetic activity, and impairment in sleep duration and architecture.
- 6. Variable emotional disturbances, including fear, depression, euphoria, or perplexity.
A little on pathogenesis:
Most likely multifactorial (dah!)
1. Cortical vs subcortical mechanisms:
- Cortical:
o EEGs have shown that it is a disturbance of global cognitive functioning with ‘final common pathway’ phenomenon, regardless of etiology (EEG shows similar wave form- abnormal slow wave activity)
o EXCEPT alcohol or sedative meds associated delirium (EEG consistently shows fast wave activity)
- Subcortical:
o Subcortical structures (thalamus, basal ganglia, pontine reticular formation) all involved
o Also why patients with disorders in these areas (eg Parkinsons’) are more susceptible
2. Neurotransmitters and humoral mechanisms:
- Acetylcholine has the most evidence for playing a major role (mainly due to ↓ acetylcholine leves eg through ↑anticholinergic use etc)
Risk factors:
- Underlying brain diseases/disorders: eg Dementia, stroke, Parkinson’s
- Advanced age
- Sensory impairment (??)
Assessing for delirium
Confusion assessment method (CAM) is superior to MMSE (as per uptodate), the latter having the least accurate results.
Feature1. Acute onset and fluctuating course
Assessment
:Usually obtained from a family member or nurse and shown by positive responses to the following questions:
“Is there evidence of an acute change in mental status from the patient’s baseline?”;
“Did the abnormal behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?”
Feature2:Inattention
Assessment
Shown by a positive response to the following:
“Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?”
Feature3: Disorganized thinking
Assessment
Shown by a positive response to the following:
“Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?”
Feature 4
Assessment
Shown by any answer other than “alert” to the following:
“Overall, how would you rate this patient’s level ofconsciousness?”
Normal = alert
Hyperalert = vigilant
Drowsy, easily aroused = lethargic
Difficult to arouse = stupor
Unarousable = coma
*The diagnosis of delirium requires the presence of features 1 AND 2 plus either 3 OR 4.
Dementia
Definition (DSMIV):
- Impairment of memory PLUS at least one other cognitive domain (from the following):
o Impairment of handling complex tasks
o Impairment in reasoning ability
o Impaired spatial ability and orientation
o Impaired language
- Other features:
o The cognitive impairment must impact on social/emotional/professional activity
o Must represent a significant decline/change from previous functioning
o Impairment is insidious/chronic in onset
o Impairment is not better accounted for by delirium, major psych problem, systemic/other brain disease
Comparison to delirium: Dementia-
- Chronicity: usually gradual/insidious onset (months-years), no fluctuation
- No inattention: attention is relatively intact
- N.B Psychomotor disturbances can occur (esp in Lewy body with visual hallucinations and fluctuations)
Considering the answers:
A. Inability to count backwards from 30 -> demonstrates inattention (seen in delirium not dementia)
B. Failure to recall 3 items after a 3-minute delay -> memory problems occur in both
C. Disorientation in time and place but not person -> can occur in both
D. Paranoid delusions -> can occur in both
E. Sleep-wake disturbance with nocturnal wandering -> not specific to either
Which clinical feature of delirium is most useful for differentiating it from dementia?
A. Inability to count backwards from 30.
B. Failure to recall 3 items after a three-minute delay.
C. Disorientation in time and place but not person.
D. Paranoid delusions.
E. Sleep-wake disturbance with nocturnal wandering.
ANSWER: A
Discussion
- Delirum: Clinically delirium may be the only finding suggesting acute illness in older demented patients
- • acuteness of presentation is most helpful feature in differentiating delirium from dementia
- typically develops over a short period of time and tends to fluctuate during course of the day
- psychomotor agitation, sleep-wake reversals, irritability, anxiety, emotional lability, hypersensitivity to lights and sounds
- disturbance typically caused by a medical condition, substance intoxication, or medication side effect
- disturbance of consciousness
- change in level of awareness and ability to focus, sustain, or shift attention
- loss of mental clarity is often subtle and may precede more flagrant signs of delirium by one day or more
- Distractibility is often evident in conversation
- Patients will appear obviously drowsy, lethargic, or even semi-comatose in more advanced cases of delirium
11. - In contrast to delirium, cognitive change is typically insidious, progressive, without much fluctuation, and occurs over a much longer time (months to years). Attention is relatively intact, as are remote memories in earlier stages
• altered cognition
• cognitive and perceptual problems, including memory loss, disorientation, and difficulty with language and speech
• perceptual disturbances
• vague delusions of harm
• visual and tactile hallucinations are uncommonly reported
• may lose the ability to write or to speak a second language
• temporal course
• develops over hours to days and typically persists for days to months - • features of delirium are unstable, typically becoming most severe in evening and at night
Confusion assessment method (CAM) for diagnosis of delirium
Feature
- Assessment of delirium
- Acute onset and fluctuating course
Usually obtained from a family member or nurse and shown by positive responses to the following questions:
“Is there evidence of an acute change in mental status from the patient’s baseline?”
“Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?”
- Acute onset and fluctuating course
- Inattention
“Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?” - Disorganized thinking - “Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?”
- Altered level of consciousness, shown by any answer other than “alert” to the following:
“Overall, how would you rate this patient’s level of consciousness?”
Normal = alert
Hyperalert = vigilant
Drowsy, easily aroused = lethargic
Difficult to arouse = stupor
Unarousable = coma
A 73yr old man is referred for assessment of testamentary capacity. There is a past history of excessive alcohol consumption and hypertension. Over the last 6 months, he has been more forgetful and irritable with occasional socially inappropriate behaviour. His speech is fluent and comprehension normal. There are no focal neurological findings. Testamentary capacity can be best established by which of the following?
A. Clinical assessment
B. Neuro-imaging
C. Formal neuropsychological testing
D. Interview of family members
E. Mini-mental state examination
Answer: A - Clinical assessment
Discussion:
Testamentary capacity (TC)
General:
- refers to the legal status of being capable of executing a will; specifically referring to the ability to make meaningful and authentic decisions
- Challenges to TC are made on a legal basis; the judge remains the final arbiter. However, medical assessment may be sought to support a challenge.
The role of the medical assessor:
- Usually geriatricians/psychogeriatricians. In difficult cases, neuropsych assessment can help make the decision
- Recommended to assess >1 interview to make an accurate assessment of mental capacity:
o Minimum is over 2 separate consultations where 2nd is on same day that the px executes the will
- Assessment:
o Interview questions (to ask testor):
Explain effects of will and what will happen to property if they don’t make one
Give estimate of property value
Describe reasoning behind decisions to include/exclude potential heirs
Whether they understand that current will revokes previous will
- Clinical assessment re: any medical condition precluding capacity
o Includes potential signs of incapacity:
Attention/information processing difficulties
Language difficulty, spatial difficulty, memory difficulty, impairment of higher executive function
Determining Capacity (Criteria): - Banks vs Goodfellow legal case (1870) remains hallmark for defining criteria for testamentary capacity in Australia/Common law countries - As stated in Medical Practitioners Board of Vic and AMA vic websites, there are 4 requirements for TC o 1. The testor must understand that he is giving instructions for the disposal of his property after his death o 2. Must be of sound disposing mind- i.e must recollect the extent and character of his property and dispose of it with ‘understanding and reason’ o 3. Recall and understand the claims of potential heirs o 4. No disorder of mind such as delusions or hallucinations which would influence his decisions N.B A will made during periods of lucency interspersed within delusions is considered valid
Common Cognitive Screening Tests (and their use):
- In general, cognitive screening tests are not adequate for assessing capacity
- 1. MMSE:
o Most commonly used screening examination
o Limitations:
Does not test specifically for frontal or executive brain functions
In general, scores <26 suggest that a person is impaired, but scores may be significantly influenced by factors such as native language, education, and premorbid IQ
- 2. Clock- Drawing Test:
o Useful as a cognitive screen because it covers many different areas including comprehension, planning, visual memory, motor programming and execution etc
Cholinesterase inhibitors are prescribed for Alzheimer’s disease. Which of the following is a typical dose-dependent (type A) adverse drug reaction expected with this group of drugs?
A. Bradycardia
B. Urinary retention
C. Constipation
D. Dry mucous membranes
E. Extrapyramidal movements
Answer: A - Bradycardia
Discussion:
Alzheimer’s medications
- Accumulation of beta-amyloid peptide results in destruction of cholinergic neurones ↓ Acetylcholine (ACh) concentration
- None of the available drugs prevents Alzheimer’s disease or modifies its pathology
- Both Anticholinesterases and memantine (N-methyl-D-aspartate antagonist) are approved for rx. At best, they show modest efficacy in:
o Improving cognition and/or
o Reducing rate of cognitive and functional decline
o N.B Clinical usefulness and effect on QOL remains uncertain
- Combination treatment improve outcomes
- Optimal duration of treatment: unclear, some evidence that px benefit for up to 3 years
Cholinesterases
There are 2 types of cholinesterase enzyme:
- Acetylcholinesterase (true cholinesterase); butyrylcholinesterase/plasma cholinesterase (pseudocholinesterase)
- Closely related in molecular structure, differ in distribution, substrate specificity, and function
- Acetylcholinesterase:
o Present at all cholinergic junctions
o Bound to BM in synaptic clefts where it hydrolyses released Ach
o Insoluble form: found in the erythryocyte; function unknown
o Soluble form: present in the CSF and cholinergic nerve terminals
- Butyrylcholinesterase:
o Physiological function unknown
o Insoluble form: found in liver, skin GI smooth muscle, kidneys, brain
o Soluble form: found in plasma
Cholinesterase inhibitors
General:
- Prolong the existence of Ach after it is released from cholinergic nerve ending by inhibiting both acetylcholinesterase and butyrylcholinesterase
- Produce effects equivalent to excessive stimulation of the cholinergic system; ie. Stimulation of:
o Muscarinic receptor responses at autonomic effector organs
o Autonomic ganglia and skeletal muscle (then depression of these)
o Cholinergic receptor in CNS
Types:
- Donepezil (Aricept), Galantamine, Rivastigmine
- Comparative info (only few comparative trials)
o All seem to have similar efficacy
o At full dose rivastigmine may have more GI adverse effects
Effects in AD:
- Delay in deterioration of cognition by 6 months (25-50%); and by 1 year (12-20%)
- No reliable predictors of response; if unresponsive to one may show improvement when switched to another
Mode of action:
- Decreases breakdown of acetylcholine neurotransmitter by inhibiting cholinesterase ↑ level and duration of action of acetylcholine reduces the apparent deficiency of cholinergic neurotransmitter activity in Alzheimer’s disease
- Most work at neuromuscular junction
Indications:
- Mild to moderate Alzheimer’s disease
Contraindications:
- Active peptic ulcer; GI or ureteric obstruction
Adverse effects:
- Mainly due to increased activity of the autonomic/parasympathetic nervous system chronic stimulation of muscarinic acetylcholine receptors
- Common:
o GIT: N/V/D, anorexia, abdo pain, dyspepsia
o Neuro: tremor, muscle cramps (due to ↑action at NMJ), urinary incontinence
- Infrequent/rare:
o CVS: Syncope, bradycardia, heart block, hypertension
o Psych: agitating, hallucination, confusion
o GIT: GI haemorrhage
o Other: seizures
- Mnemonics describing some of above:
o ‘SLUDGE-M: Salivation; Lacrimation; Urination; Defacation; GI; Emesis; Muscle cramps/Miosis
o ‘DUMBELSS’: Diarrhoea, urination, Miosis/muscle cramps, bradycardia, emesis, lacrimation, salivation/sweating
Donepezil
Pharmacodynamics:
- Specific and reversible inhibitor of acetylcholinesterase
- Single daily dose of 5 or 10mg produces steady-state inhibition of acetylcholinesterase activity
Pharmacokinetics:
- Oral bioavailability of 100%; reaches peak plasma concentration in 3-4 hours
- Half-life ~70hrs, steady-state reached within ~3/52 of initiation of therapy. Once at steady state activity and concentration show little variability over the course of the day
Trials:
- Two double blind randomised trials; 436px over 15-30wks
o Statistically significant drug/ placebo differences for each of the two primary outcome measures (ADAS-cog and CIBIC Plus)- i.e:
ADAS-cog: memory, orientation, attention, reason, language and praxis.
CIBIC Plus: global measure of change in patient functionality that is derived through evaluation of four major areas of functioning (general, cognition, behaviour and activities of daily living).
- 5mg vs 10mg: no statistical difference
Effects on the ADAS-cog: Figure 1After 24 weeks of treatment the mean differences in the ADAS-cog change scores for Aricept treated patients compared to the patients on placebo were 2.8 and 3.1 units for the 5 and 10 mg/day treatments, respectively. These differences were statistically significant. While the treatment effect size may appear to be slightly greater for the 10 mg/day treatment, there was no statistically significant difference between the two active treatments.
- Long term effect post discontinuation:
o Benefits of effect decrease over 6/52 post discontinuation; no evidence of rebound effect 6/52 after abrupt discontinuation of rx
Comments on answers
B. Urinary retention: no urinary incontinence
C. Constipation: no diarrhoea
D. Dry mucous membranes: no ↑secretion and sweating
E. Extrapyramidal movements: No, no dopamine antagonism
A 90-year old male resident of a nursing home has severe dementia. He is bedbound, mute, doubly incontinent and requires full nursing care. He has a large pressure area over one buttock. He has had 2 recent admissions to hospital with aspiration pneumonia and has been placed on thickened fluids to try to prevent aspiration. He does not have any close family members. Now he does not co-operate with feeding and when food is placed in his mouth he does not swallow it. In the absence of any advance directives, the most appropriate approach to the management of his hydration and nutrition is:
A. Percutaneous endoscopic gastrostomy (PEG) tube feeding
B. Nasogastric tube feeding
C. IV fluids
D. Overnight subcutaneous fluids
E. Mouth care
Answer E - mouth care
Discussion:
The non-treatment consensus in dementia
Mental Capacity Act 2005
- Allows people to express a wish about how they would like to be treated should they lose capacity.
- It would not allow the refusal of basic care, but includes refusing certain treatments such as artificial nutrition and hydration.
- They must also involve the view of carers
BMJ article 1994: Witholding and withdrawing life treatment in elderly people
- Irrespective of age, all adult px who are competent to consent to life prolonging treatment are also competent to refuse it.
- 2 exceptions for not treating in a competent px:
o 1. Clinical evidence exists that a discussion of non-treatment may endanger the patient’s health
o 2. Treatment would be futile in that it would not achieve its physiological objective
- Justifiable conditions for non-treatment in incompetent patients (5):
o 1. Imminent and irreversible closeness to death
o 2. Extensive neurological damage leading to the permanent destruction of both self awareness and intentional action
o 3. Little self-awareness accompanied by such severe motor disability that sustained independent and intentional action becomes impossible
o 4. Destruction of both long and short term memory to such a degree that the person who used to exist no longer does and no other person can evolve instead
o 5. Severely limited understanding by the patient of distressing and marginally effective lifesaving treatment that leads to a demonstrably awful life
Alzheimer’s Society (2010):
- “Quality of life rather than length of life should be prioritised”
- Re: artificial hydration and nutrition:
o “It is inappropriate for a person with advanced dementia to be given artificial hydration and nutrition for the sole purpose of prolonging life”
o “Treatment should be given to maximise the quality of life and comfort of a person with dementia, in accordance with the General Medical Council’s guidelines (2010)”
o “Difficulty with swallowing in the late stages of dementia is common, and most people accept that this is part of the dying process and that most appropriate response is palliative care
o Sips of water to moisten the person’s mouth provide a more appropriate and less invasive alternative to artificial hydration.
