Geratology Flashcards
Describe the presentation of a stroke
- Sudden onset
- limb weakness
-Facial weakness
-Dysphasia
-Visual field defect
-Sensory loss
-Ataxia and vertigo
In stroke what does ataxia and vertigo indicate?
The posterior circulation is affected
List the risk factors for stroke
-Previous TIA
-AF
-carotid artery stenosis
-Hypertension
-Diabetes
-High cholesterol
-Family history
-Smoking
-Obesity
-Vasculitis
-Thrombophilia
-Combined oral contraceptive
In which people does the combined oral contraception increase the risk of stroke?
The risk is higher if the person has migraines, is over 34, smokes or has a history of a stroke/TIA
What is important to do before treating someone for a stroke?
Exclude hypoglycaemia
When using the ROSIER tool to assess for stroke what score indicates a stroke being likely?
Above 1
Which symptoms on the ROSIER tool give a -1 score?
-Loss of consciousness
-Seizure activity
Which symptoms of the ROSIER tool give a +1 score?
-Asymmetrical facial weakness
-Asymmetrical arm weakness
-Asymmetrical leg weakness
-Speech disturbance
-Visual field defect
Describe the findings of a non contrast CT head with an ischaemic stroke.
-Low density grey and white matter in 1 area which may take time to show up
-Hyperdense artery, visible immediately with a visible clot
Describe the findings of a non contrast CT head with a haemorrhagic stroke.
Areas of hyper density (blood), surrounded by low density (oedema)
Describe the management of an ischaemic stroke
-Exclude hypoglycaemia
-Immediate non contrast CT brain
-300mg aspirin
-Admission to specialist stroke centre
-Thrombolysis with alteplase (within 4.5 hours of onset)
-Thrombectomy (within 24 hours)
- Investigate for carotid artery stenosis and AF
What is the mechanism by which alteplase works?
It’s a tissue plasminogen activator
What are the absolute contraindications of alteplase?
-Previous intracranial haemorrhage
-Seizure at onset of stroke
- intracranial neoplasm
-Suspected subarachnoid haemorrhage
-Stroke caused by traumatic brain injury preceding 7 days
-Gi bleed preceding 3 weeks
-active bleeding
-pregnancy
-oesophageal varices
-Uncontrolled hypertension (2oo/120hg)
What are the relative contraindications of alteplase?
-concurrent anticoagulation, INR above 1.7
-Haemorrhagic diatheses (tendency to bleed)
-diabetic haemorrhagic retinopathy
-suspected intracardiac thrombus
-major surgery preceding 2 weeks
Why shouldn’t lowering BP be done generally in ischaemic stroke?
It will worsen the ischaemia
In ischaemic stroke when can hypertension be treated?
- In hypertensive emergency
Which areas of circulation can a thrombectomy be used?
Proximal anterior circulation or proximal posterior circulation (basilar or posterior cerebral artery)
What can be used to identify the area where a clot is in circulation?
Computed tomographic angiography or magnetic resonance angiography
How are haemorrhagic stroked treated?
- exclude hypoglycaemia
- lower blood pressure
- reverse effects of anticoagulant medicines
-emergency craniotomy
In patients with AF when is anticoagulation resumed after a stroke?
14 days after
How is carotid stenosis investigated and treated?
-carotid ultrasound
-carotid artery endarterectomy/ angioplasty/ stenting
Describe secondary stroke prevention
- Clopidogrel 75mg/day
-Atorvastatin 20-80mg delayed 24 hours
-Bp and diabetes control
-altering modifiable RF
Define a TIA
Temporary neurological dysfunction lasting less than 24 hours (usually less than 1hour)
In a TIA which areas are ischaemic?
could be:
-focal brain
-spinal
-retinal
What is a crescendo TIA and what does it indicate?
2 or more TIA’s within a week, high risk of stroke
What is the management of TIA?
-3oomg/day aspirin
-referral for specialist assessment within 24 hours if it happened within the past week
-referral for specialist assessment within a week if it happened more than a week ago
- diffusion weighted MRI
-carotid imaging
Describe the mechanism of aspirin
-NSAID
-blocks cyclooxygenase-1 and 2, cyclooxygenase-1/2 is responsible for thromboxane synthesis
- stops platelet aggregation
Describe the mechanism of clopidogrel
-It’s a thienopyridine
-Inhibits platelet activation by being a P2Y12 adenosine diphosphate receptor antagonist
What drug is 1st line in an ischaemic stroke?
Clopidogrel
What can make clopidogrel less effective?
Repeated PPI use
Describe benign paroxysmal positional vertigo
-triggered by head movement
-peripheral cause
settles after 20-60 seconds
-no hearing loss or tinnitus
Describe the pathophysiology of benign paroxysmal positional vertigo
-Calcium carbonate crystals (otoconia) displaced in the semi-circular canals
-Disrupts normal flow of endolymph, disrupts the vestibular system= vertigo
Which semi-circular canal are the calcium carbonate crystals usually displaced into?
posterior semi-circular canal
What can displace the calcium carbonate crystals?
Viral infection, head trauma, ageing, idiopathic
describe the dix-hallpike manoeuvre
-Move head to initiate vertigo
-check pain in the neck
-check for rotational nystagmus towards affected ear
What is the main treatment for benign paroxysmal positional vertigo?
The Epley manoeuvre, effective in 80% of patients
What are brandt-daroff exercises?
Exercises performed at home to improve paroxysmal benign positional vertigo symptoms at home.
what is delirium?
Impaired mental state
What causes delirium? (PINCH ME)
Pain/post surgery
Infection
Nutrition
Confusion/ constipation
Hydration/ hypoxia
Medication
Environment / electrolyte disturbances
and renal failure
What makes someone more likely to be experiencing delirium than dementia?
-Acute
-Impaired consciousness
-fluctuating symptoms (worse at night)
-abnormal perception
- agitation and fear
-delusions
What are the types of delirium?
Hyperactive, hypoactive and mixed state
Describe hypoactive delirium
sluggish
drowsy
less reactive
sullen
looks withdrawn
List risk factors for delirium
- recent surgery (narcotic pain relief, benzodiazepines, hypnotics, anticholinergics)
-underlying disease
-chronic fatigue
-co-morbities (dementia, constipation, pneumonia, UTI
How to de- escalate a situation with delirium?
Provide routine
glasses
hearing aids
constipation
sleep
In ICU what is used to sedate people?
dexmetomide
What is the most common type of dementia in the UK?
Alzheimer’s
What is the peak incidence of Alzheimer’s?
70
Describe the genetic factors involved in Alzheimer’s disease.
- 5% inherited autosomal dominant
-mutations in the amyloid precursor gene (chromosome 21), presenilin 1(chromosome 14), presenilin 2(chromosome 1)
-apoprotein E, allele E4
-down syndrome
What is apoprotein E?
Cholesterol transport protein
Describe the macroscopic pathological changes in Alzheimer’s
Cerebral atrophy (particularly in the cortex and hippocampus)
Describe the microscopic pathological changes in Alzheimer’s
-cortical plaques
-deposition of A-beta- amyloid
-Intraneuronal neurofibrillary tangles
What causes neurofibrillary tangles in Alzheimer’s?
abnormal aggregation of tau protein, hyperphosphorylation also linked
What is the roll of tau protein?
Interacts with tubulin to stabilise microtubules
what is there a deficit of in AD?
acetylcholine
Describe the general features of AD
-occurs over months/ years
-difficulty with daily living
Describe the cognitive impairment associated with AD
-memory loss
-difficulty learning new information
-vague with dates
-reasoning and communication
-difficulty making decisions
-dysphasia
Describe the behavioural and psychological features associated with AD
-depression
-agitation
-psychosis
-apathy
-disinhibition
Describe the non-pharmacological treatments for AD
-social prescribing
-group cognitive stimulation therapy (mild and moderate)
-group reminiscence therapy
describe the pharmacological treatment for AD
- 3 acetylcholinesterase inhibitors
-memantine
When are acetylcholinesterase inhibitors used in AD?
in mild- moderate Alzheimer’s
Name 3 acetylcholinesterase inhibitors
-Donepezil
-galantamine
-rivastigmine
What is contraindicative of acetylcholinesterase inhibitors?
bradycardia
What is a common side effect of anticholinesterases?
insomnia
What class of drug is memantine?
NMDA receptor antagonist
When is memantine used?
-moderate Alzheimer’s where acetylcholinesterase’s aren’t tolerated
- add on in moderate/severe Alzheimer’s
-monotherapy in severe Alzheimer’s
Are antidepressants used to treat low mode is AD?
no
What are used to treat patients at risk of hurting themselves or other who have AD?
antipsychotics
How common is vascular dementia?
2nd most common type of dementia
List risk factors of vascular dementia
-TIA history
-AF
-Hypertension
-DM
-hyperlipidaemia
-smoking
-obesity
-CHD
-FH stroke or CVD
-
Can vascular dementia be inherited?
-yes
-cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
How can vascular dementia be sub categorised?
-Stroke related (multi infarct or single infarct dementia)
-subcortical (small vessel disease)
-mixed (VD+ AD)
What is the timescale for the presentation of vascular dementia?
-Stepwise progression
-months/years
List the symptoms of vascular dementia
-Focal neurological symptoms
-Difficulty with attention / focusing
-seizures
-memory disturbances
-gait disturbances
-speech disturbances
-emotional disturbance
How would vascular dementia be diagnosed?
-History and examination
-Formal screen for cognitive impairment
-Medical review to exclude prolonged medication as a cause
-MRI- infarcts in the white matter
Describe the non pharmacological treatment for vascular dementia
-Cognitive stimulation
-Multisensory stimulation
-music and art therapy
-animal assisted therapy
Describe the pharmacological treatment for vascular dementia
-Treat symptoms
-Address and treat cardiac risk factors
- No pharmacological treatment specifically for vascular dementia
Describe the pathophysiology of Parkinson’s disease.
- Basal ganglia coordinate habitual movements, control voluntary movements and specific learning patterns
-Dopamine is essential to basal ganglia functioning
-There’s a progressive reduction in dopamine which results in movement disorders
Describe the classic triad of Parkinson’s
-Resting tremor
-Cogwheel rigidity ( resisting passive movement)
-Bradykinesia
Describe the features of the tremor associated with Parkinson’s disease
- worse on one side
-4-6 hertz
-pill rolling tremor
-more noticeable at rest
-better with voluntary movement
-worse when the patient is distracted
-using the other hand exaggerates the tremor
Describe the features of the bradykinesia associated with Parkinson’s disease
-Micrographia
-shuffling gait
-festinating gait
-difficulty initiating movements
-Lots of small steps when turning
-hypomimia
List some features of Parkinson’s disease
-depression
-sleep disturbance
-insomnia
-anosmia
-postural instability
-cognitive impairment and memory problems
How can we differentiate between a Parkinson’s tremor and a benign essential tremor
Benign essential tremor:
- symmetrical
-6-12 hertz
-improves at rest
-worse with intentional movement
-no other Parkinson’s features
-Improves with alcohol
Parkinson’s:
-asymmetrical
-4-6 hertz
-worse at rest
-improves with intentional movement
-other Parkinson’s features
-No change with alcohol
What has a similar presentation to Parkinson’s disease?
Multiple system atrophy
Dementia with lewy bodies
Describe multiple system atrophy
-Various systems in the brain degenerate (including the basal ganglia) which can lead to a Parkinson’s presentation
-Cerebellar dysfunction (ataxia)
-Other area degeneration, autonomic dysfunction
Which type of dementia is associated with Parkinson’s?
Dementia with Lewy bodies
How is Parkinson’s diagnosed?
- History and examination
-UK Parkinson’s disease society brain bank clinical diagnostic criteria
What is the approach to treating Parkinson’s?
Treating for symptomatic relief not for a cure
What is the most effective treatment for Parkinson’s disease and what is it’s main issue?
-Levodopa
-less effective over time
What are the side effects of Levodopa?
-Dystonia
-chorea (involuntary irregular movements)
-athetosis (slow continuous involuntary writhing movement)
what is levodopa combined with when treating Parkinson’s disease and why?
-Peripheral decarboxylase inhibitors
-Stops L-dopa being metabolised peripherally before it reaches the brain
What is levodopa?
synthetic dopamine
Name 2 peripheral carboxylase inhibitors
-carbidopa
-benserazide
name 2 combination drug names for l-dopa and a peripheral carboxylase inhibitor
-Co-beledopa (madopa)
-Co-carledopa (sinemet)
What does COMPT stand for?
catechol-o-methyl transferase
What does the COMPT enzyme do?
metabolises levodopa peripherally
Name a COMPT inhibitor and what it’s used for
-Entacopone
-taken with levodopa to slow down it’s break down
