general

Question 1

what is sarcopenia

Answer 1

age related, involuntary loss of skeletal muscle mass and strength

Question 2

what blood pressure is associated with increased risk of falls in the elderly

Answer 2

systolic BP of 120 or below

Question 3

possible causes of peripheral neuropathy

Answer 3

• diabetes
• alcohol
• vit B12 deficiency

Question 4

what is orthostatic hypotension

Answer 4

a form of low blood pressure that happens when standing after sitting or lying down

Question 5

causes of orthostatic hypotension

Answer 5

• baroreflex dysfunction
• triggered by medications or other circumstances such as prolonged bed rest
• many disease e.g. diabetes, amyloidosis
• parkinsons and lewy body dementia

Question 6

some culprit drugs to be stopped in orthostatic hypotension

Answer 6

• diuretics
• anti-hypertensives
• dopamine agonists
• pregabalin
• review anti-depressants

Question 7

management of orthostatic hypotension

Answer 7

• stop culprit drugs
• avoid sudden changes in movement
• ‘water loading’
• Increase salt in diet
• Compression stockings
• Keep legs elevated when sitting/sleeping.
• Calf muscle exercises when standing for prolonged periods

Question 8

when conservative measurements have failed for orthostatic hypotension, what is the management

Answer 8

consider medication – fludrocortisone, midodrine

Question 9

falls investigations

Answer 9

• ECG +/- telemetry
• Check blood sugar
• Postural BP’s – lying, standing 0 min, 1 min, 3 min
• Timed Up and Go
• Echocardiogram if indicated
• Consider CT Head
• Consider further tests e.g. ambulatory ECG, carotid sinus massage, tilt-table testing if available

Question 10

what is carotid sinus syndrome

Answer 10

a type of reflex syncope or near-syncope with symptoms (eg, syncope, lightheadedness) caused by carotid sinus hypersensitivity manifesting during activities of daily life that put pressure on the carotid sinus (eg, turning the neck, looking upward). When CSS manifests as syncope it is called carotid sinus syncope

Question 11

signs of active dying (last breath mneumonic)

Answer 11

Lethargy
Altered mental state
Skin changes
Tablets and oral intake diminished or stopped
Breathing changes - rattly, rapid, intermittent

Question 12

what are some treatable conditions that can mimic dying

Answer 12

Opioid toxicity
Sepsis
Hypercalcaemia
Hypoglycaemia
Uraemia/AKI

Question 13

in end of life care, what medication can be used for pain/SOB

Answer 13

morphine (or other strong opioid) 2mg hourly

Question 14

in end of life care, what medication can be used for distress/agitation

Answer 14

midazolam 2mg hourly

Question 15

in end of life care, what medication can be used for nausea

Answer 15

levomepromazine 2.5mg 12 hourly

Question 16

in end of life care, what medication can be used for respiratory secretions

Answer 16

hyoscine butylbromide 20mg hourly

Question 17

when starting opioids for anticipatory medications, what approach would we take if the patient is on a background opioid already?

Answer 17

• Generally, use same opioid for background and prn
• Use approx. 1/6 background dose as breakthrough prn dose
• Switch background oral opioid to syringe driver if not managing to swallow

Question 18

anticipatory medications -which strong opioid is safer in renal impairment

Answer 18

alfentanil

Question 19

what are syringe drivers used for

Answer 19

Allow us to give background medications to people who can’t take them by mouth
Including in last days of life when conscious level often reduced

Medications are given continuously over 24hours by subcutaneous infusion

Question 20

how often do syringe drivers need changed

Answer 20

daily

Question 21

which is stronger - SCUT morphine or ORAL morphine?

Answer 21

SCUT morphine is twice as strong as ORAL morphine

Question 22

do most people who are dying have a syringe driver

Answer 22

no, many people who die don’t need one

Question 23

what are the steps in confirmation of death procedure

Answer 23

absence of carotid pulse over one minute confirmed
AND
absence of heart sounds over one minute confirmed
AND
absence of respiratory sounds/effort over one minute confirmed
AND
no response to painful stimuli (e.g. trapezius squeeze)
AND
fixed dilated pupils (unresponsive to bright light)