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FM Flashcards

1
Q

RAPRIOP

A
  1. Reassurance and explanation, address ICE
  2. Advice and counselling
  3. Prescribing
  4. Referral
  5. Ix
  6. Observation and FU
  7. Prevention
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2
Q

HASBLED score

for 1y major bleeding risk of AF; for Warfarin; now also for NOAC

A 
HT
Abnormal L/RFT
Stroke hx
Bleeding tendency / predisposition (e.g. anemia)
Labile INR
Elderly (>65)
Drugs (Aspirin, NSAID, alcohol)
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3
Q

BPPV presentation

JC WCS

A

Benign paroxysmal positional vertigo

  1. No hearing symptom
  2. Usually last for about 3wk
  3. Recurrence common
  4. Provoke by turning over to particular position in bed or when reaching up
  5. Wakes in sleep
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4
Q

Tx of BPPV

JC WCS

A
  • Epley’s maneuver (Therapeutic)
  • Reassurance
  • Waiting + vestibular sedatives
  • Avoid driving
  • 45o prop up or 2 high pillows
  • Don’t sleep on side of bad ear
  • Keep head still at vertical position (i.e. not bend -
    forward/backward)
  • Repositioning maneuvers
  • Surgery (High risk of severe sensorineural hearing loss)
  • Posterior ampullary nerve section
  • Posterior canal obliteration
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5
Q

Nutritional needs for elderly

Geri

A

Fat/Carb/Dietary fiber same as young ppl

Per week

  • 2x portion of fish (1=oily fish with omega-3 FA and vit D)
  • Fruits, vegetables (with a variety of vitamins and minerals)
  • Fiber, probiotics (preserved food, yogurt - gut health)
  • Additional vit D supplement for older
  • Protein intake (more than young adults; at least 1-1.2g/kg/day)

*use Dietary reference intakes (DRI) calculator

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6
Q

Causes of Dysphagia

Geri

A

Oro-pharyngeal vs Esophageal dysphagia

Oro: Difficulty initiating swallowing +/- chocking or aspiration

Eso: Food sticking after swallowing +/- regurgitation

Oro: Stroke, dementia, PD, bulbar/pseudobulbar palsy, MG

VFSS, Neuro Ix

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7
Q

3 phases of swallowing

A
  1. Oral
  2. Pharyngeal
  3. Esophageal
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8
Q

Bedside swallowing test

Geri

A
  1. Screening
  2. Give 1 tea spoon of water + feel throat (x3 attempt)
  3. Give 60-90ml of water + feel throat

All safe then Diet as tolerated (DAT)
Any problem –> refer SLT (Speech and language therapist), keep NPO

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9
Q

Clinical signs of aspiration

Geri

A
  1. Wet/gurgly/abnormal voice quality
  2. Coughing/Choking
  3. Tachypnea
  4. Eyes watering
  5. Repeated throat clearing
  6. O2 desaturation >=2%
  7. Pneumonia
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10
Q

Mx for Dysphagia

Geri

A
  1. Optimize eating/drinking position (seated at a table, propped up in bed, sit up 90o, chin down)
  2. Altered consistency of food/drinks
  3. NG feeding (does not reduce risk of aspiration, uncomfortable, restrain, low QOL)
  4. PEG feeding (can still aspirate stomach content, more invasive, more comfortable in long term, PEJ to reduce risk of aspiration)
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11
Q

Causes of Fall

Geri

A
  1. LOC – syncope or pre-syncope
  2. Loss of strength, balance or coordination
  3. External force (pushed over)
  4. Sudden uncontrolled symptom – chest pain, seizure
  5. Undetermined, e.g. rolled out of bed (reason could be REM sleep disorders, postural hypotension when getting up for toilet)
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12
Q

Ix for Fall

Geri

A

Neuro

  • CT brain
  • MRI brain
  • Carotid sinus massage (rub 1 at a time to see which side has problem; massage + ECG at same time)
  • Dix-Hallpike test

CVS

  • ECG
  • 24h Holter / 7d Holter
  • Echo
  • Erect/Supine BP
  • Tilt table test

Others

  • CBC
  • Thyroid function
  • Biochem
  • DH
  • BP diary
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13
Q

Timed up and go test

Geri

A

<10s = Normal
>14s = ↑Fall risk
<20s = Can still go out alone
>30s = ADL dependent

  • With or without armrest (w/o is more difficult)
  • Walking aids allowed
  • No personal assistance

Step 1: Begin the test with the patient sitting in the chair with his/her hips all the way to the back of the seat

Step 2: Start timer on the word Go. Patient walks 3 meters and turns around

Step 3: Stop the timer when patient sits down

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14
Q

Medical interventions to prevent falls

Geri

A
  1. Treat underlying conditions, e.g. cardiac arrhythmia
  2. Treat postural hypotension, e.g.
    - Fludrocortisone 100-400mcg OD [Monitor RFT, may ↑Na, ↓K]
    - Use Midodrine (AB) if Fludro doesn’t work
    - Compression stockings
  3. Treat sarcopenia, e.g. Protein supplements
  4. Modification of RFs, e.g. BMD, weight
  5. Vit D can reduce fall risk for OAH residents (cuz Vit D + protein = muscles)
  6. Med adjustment, e.g. night sedation

**Fall is not absolute CI for NOAC or Warfarin

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15
Q

Therapy to prevent falls

Geri

A
  1. PT = Group + home based therapy
    - Strength + balance + flexibility exercises, e.g. Tai Chi
  2. OT = Environmental adaptation, e.g. safety rails in showers
    - Footwear, sight correction, hip protector
    - Home installed alarm system
  3. Refer to Day hospital, Elderly centers, NGOs
  4. Community services
  5. MSW for home care, financial help
  6. Comprehensive geriatric assessment (CGA)
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16
Q

Counsel for Fall

Geri

A
  1. Find out everything you need to assess fall risk
  2. Find out caring issues, living environment
  3. Find out effect on basic & instrumental ADLs
  4. Explore physical consequences, e.g. fractures, head injury
  5. Explore psychological effects, e.g. fear of going out
  6. Explore carer burden
  7. Explain level of risk
  8. Explain medical & therapy tx options
  9. Empower by educating and teaching how to self-help
  10. Reassure and manage expectations by patient & family
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17
Q

Major RF for stroke (similar for ischemic/hemorrhagic)

Geri

A

Modifiable

  1. HT / DM / HL
  2. Smoking / Alcohol abuse
  3. AF
  4. Carotid stenosis
  5. Physical inactivity
  6. Obesity

Non-modifiable

  1. Age
  2. Sex
  3. Race/ethnicity
  4. Heredity

Unclear: Hyperhomocysteinemia, other cardiac disease, HRT

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18
Q

Major preventive strategies for stroke (RF control)

Geri

A
  • Lifestyle modifications: Diet, exercise, weight, smoking
  • BP: aim 130/80 (start tx if 150/90)
  • DM: aim A1c <7%
  • Lipid: aim LDL <2 (start tx at 2.5/2.69)
  • Carotid stenosis: Carotid endarterectomy or stenting
  • AF: anticoagulation
  • Antiplatelet: Aspirin/Clopidogrel/Aspirin+Dipyridamole/Cilostazol (wiki: for Intermittent claudication)
19
Q

CHA2DS2VASc score
(for non-valvular AF)
Geri

A
  • CHF
  • HT
  • Age >75
  • DM
  • Stroke
  • Vascular disease (MI, PVD)
  • Age 65-74
  • Sex category: Female

1: consider anticoagulation; >=2 anticoagulation indicated

CI to oral AC –> LAAO (Left atrial appendage occlusion)

20
Q

RF for Dementia

Geri

A
  1. Traumatic brain injury
  2. Mid-life obesity
  3. Mid-life HT
  4. Current smoking
  5. DM
  6. ?Hx of Depression
  7. ?Sleep disturbances
  8. ?HL
21
Q

Decreased risk for Dementia

Geri

A
  1. Years of formal education
  2. Physical activity
  3. Mediterranean diet
  4. Cognitive training (controversial)
  5. ?Moderate alcohol consumption
  6. ?Social engagement
22
Q

SCD vs MCI vs Dementia

Geri

A

Preclinical (Subjective cognitive decline SCD) “Patient knows, doctor doesn’t”

  • Silent phase: brain changes w/o measurable Sx
  • Patient may notice changes, but not detectable on tests

MCI (Mild cognitive impairment)

  • Cognitive changes of concern to patient/family
  • > =1 cognitive domains impaired significantly
  • Preserved ADL

Dementia
- Cognitive impairment severe enough to interfere with everyday abilities

23
Q

MoCA domains
(VNM ALA DO)
Geri

A

Montreal cognitive assessment

  1. Visuospatial/Executive
  2. Naming
  3. Memory
  4. Attention
  5. Language
  6. Abstraction
  7. Delayed recall
  8. Orientation
24
Q

MoCA scores

Geri

A

<= 2 centile (2 SD from mean) = Dementia, i.e. Major NCD (neuro-cognitive disorder)

<= 7 centile (1.5 SD) = MCI

<= 16 centile (1 SD) = Mild NCD

**2-16 is mild NCD; <2 is major

25
Q

AMT domains

Geri

A

Abbreviated mental test

  1. Personal recall
  2. Orientation
  3. New learning
  4. Orientation
  5. Personal recall
  6. Memory
  7. Concentration
  8. New memory recall
26
Q

BPSD symptoms

Geri

A

Behavioral and psychological symptoms of Dementia

Apathy

  • Withdrawn
  • Lacks interest
  • Amotivation

Aggression

  • Physical/Verbal aggression
  • Aggressive resistance to care

Depression

  • Sad
  • Tearful
  • Hopeless
  • Guilty
  • Anxious
  • Irritable/screaming
  • Suicidal

Mania

  • Euphoria
  • Pressured speech
  • Irritable

Agitation

  • Pacing
  • Repetitive actions
  • Dressing/undressing
  • Restless, anxious

Psychosis

  • Hallucinations
  • Delusions
  • Misidentification
  • Suspicious
27
Q

Counsel on Dementia

Geri

A
  1. Find out everything about the memory deficit
  2. Find out caring issues, living environment
  3. Effects on basic and instrumental ADLs
  4. Explore physical consequences, e.g. incontinence, falls
  5. Explore BPSD, e.g. mood, delusions, hallucinations, sleep
  6. Explore carer burden
  7. Explain common DDx
  8. Explain Dx may include normal aging (if very mild)
  9. Explain drug options, SEs
  10. Manage expectations: Tx not a cure, just delay deterioration
  11. Educate, classes, exercises, cognitive stimulation, NGOs
28
Q

Instrumental ADL
Geri

(PS CHL GMM)

Photoshop CH Lai with GM $

A
  1. Phone (Ability to use telephone)
  2. Shopping
  3. Cooking (Food preparation)
  4. Housekeeping
  5. Laundry
  6. Go out (Mode of transportation)
  7. Med (Responsibility for own medications)
  8. Money (Ability to handle finances)
29
Q

Mini nutritional assessment

Geri

A

Total 30 points

  • Screening max 14
  • Assessment max 16
24-30 =  Normal
17-23.5 = At risk of malnutrition
<17 = Malnourished
30
Q

Basic ADL
衣2 食 住2 行
(x6)

A
  1. Grooming
  2. Dressing
  3. Self-feeding
  4. Bathing
  5. Toileting
  6. Transferring

Bathel Index of ADL

  1. Bowels
  2. Bladder
  3. Grooming
  4. Toilet use
  5. Feeding
  6. Transfer
  7. Mobility
  8. Dressing
  9. Stairs
  10. Bathing
31
Q

Impairments by stroke

Cognitive functions

A

(1) Arousal and orientation
(2) Attention
(3) Memory
(4) Frontal executive function, reasoning, judgement
(5) Visuospatial perception, e.g. visual neglect, semi-neglect, agnosia
- -> Cognitive training, compensatory strategies by OT and CP

(6) Language –> assessment, training by OT

32
Q

Impairments by stroke

Sensory functions

A

(1) Vision
- Ophthalmologist
- Visual scanning to compensate for visual field loss by OT

(2) Hearing
- Prescriptions of hearing aids

(3) Body sensation (diminished or exaggerated (central pain))
–> Sensory re-education; Compensatory strategy
Medications and physical modality (e.g. TENS) to control central pain

33
Q

Impairments by stroke

Neuromusculoskeletal

A

(1) Mobility of joint, e.g. stiffness, contracture
- -> Stretching program by PT; Splintage by OT

(2) Abnormal tone, e.g. spasticity
–> Treat only if pain, interfere hygiene, or limit function
PT: ROM exercise, stretching and heat
OT: Proper positioning, splint, cast
Drugs: Baclofen, Tolperisone, Dantrolene
Botulinum toxin injection
Pheno/Alcohol nerve block or motor-point block
Surgery: +/- tendon release/transfer

(3) Hemiparesis/Hemiplegia
- Strength training, electrical stimulation (PT)

(4) Balance, coordination
- Balance, coordination training in parallel bars, balance board, use of Balance Master machine (PT)

34
Q

Impairments by stroke

Swallowing dysfunction

A

(1) Dysphagia
- Managed by ST
- NG rube / PEG if oral feeding not safe
- Control volume and consistency of food
- Proper head posture etc.

35
Q

Impairments by stroke

Voice and speech

A

Dysphonia and Dysarthria

- ST, +/- ENT

36
Q

Impairments by stroke

UG, Reproductive function

A

(1) Impairment of bladder control
(Urinary incontinence, ROU etc.)
(due to hyper-reflexic / hypocontractile bladder or impaired ability to transfer to toilet)

Tx

  • Timed void schedule, regulation of fluid intake, transfer and dressing skill training
  • Med: Anti-cholinergics for hyper-reflexic bladder
  • Catheterization for ROU
  • Use of external collecting device / diapers etc.

(2) Sexual dysfunction
- Counselling, skill training / positioning, drugs

37
Q

Impairments by stroke

Digestive system

A

(1) Impairment of bowl control (incontinence, bowel impaction)
- Timed toilet schedule
- Dietary fiber
- Training in toilet transfer
- Judicious use of laxatives

38
Q

Impairments by stroke

Emotional function

A

(1) Post-stroke depression - around 30-40%

- Counselling / psychotherapy (nurse, CP), antidepressants

39
Q

Activity limitation and Participation restriction by stroke

Communication

A

Verbal and non-verbal

  • Dysarthria/Dysphasia training by ST
  • Strategies for communication, e.g. use of communication broad
40
Q

BATHE model

A

To enable patient to share illness experience

Background
Affect
Trouble
Handling
Empathy
41
Q

4P approach

A

To explore psychosocial factors

Predisposing
Precipitating
Perpetuating
Protective

42
Q

Satir model

A 
Behavior, action, story
Coping
Feelings
Feelings about feelings
Perceptions
Expectations
Yearnings
Self
43
Q

Non-drug interventions for common mental health disorders

A
  1. CIPS
    - Active listening
    - BATHE technique
  2. Psychoeducation
    - iCBT
  3. Relaxation exercises
    - Slow breathing exercises
    - Progressive muscle relaxation
  4. Behavioral activation
    - Activity scheduling
    - Exercise prescription
  5. Training manuals and guidelines
    - Thinking healthy (for PN depression)
    - Problem management plus (for adversity)
    - Interpersonal therapy (for depression)

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