Geratology Flashcards
what is squamous cell carcinoma
rf
skin cancer.
metastases rare
smoking
long standing leg ulcers - marjolins ulcer
genetic conditions: xeroderma pigmentosum, oculocutaneous albinism
immunosuppression : following renal transplant, hiv
actinic keratoses and bowens disease
excessive exposure to sun/psoralen uva therapy
features of squamous cell carcinoma
on sun exposed sites like head and neck or dorsum of hands and arms
rapidly expanding painless ulcerate nodules
cauliflower like appearance
poss areas of bleeding
how to tx squamous cell carcinoma
surgical excision - 4mm if lesion under 20mm in diameter
if over 20 mm then margins should be 6 mm.
MOHS micrographic surgery.
prognosis of squamous cell carcinoma
good if well differentiate under 200mm and less than 2mm deep.
poor if poorly diff, over 20mm and 4mm deep and immunosuppressed
frailty means?
diminished strength
endurance
physiological function.
physical frailty
frailty phenotype
assessments for frailty
mx
fried frailty index
groningen frailty indicator .
mx : multi-component intervention like exercise, nutrition, med review
rf for falling in elderly
lower limb muscle weakness
vision problem
balance or gait disturbance - dm, ra, parkinson
polypharmacy
incontinence
over 65
fear of falling
depression
postural hypotension
arthritis in lower limb
psychoactive drug
cognitive impairement
name some qus to ask fall pt
where they fell when they fell
anyone see it
why they think they did
have they before
system review
pmh
social hx
meds that can cause postural hypotension
nitrates
diuretics
anticholinergic meds
antidepressant
beta blockers
l dopa
acei
meds associated with falls in elderly
benzodiazepines
antipsychotics
opiates
anticonvulsants
codeine
digoxin
other sedative agents
what ix would you do in falls
bedside tests: basic obs, bp, bg, urine dip and ecg
bloods: fbc u+e, lft, bone profile
imaging: cxr vt head cardiac echo
when would you do mdt assessment for fall pt?
over 65 with
over 2 falls in last 12 months
requires med tx
poor performance to complete turn 180 test or timed up and go test.
What is benign paroxysmal positional vertigo?
average age onset
mc cause of vertigo encountered
sudden onset dizziness and vertigo triggered by head position change.
55 average. less common in younger pts
peripheral cause of vertigo: issue in inner ear rather than brain.
features of benign paroxysmal positional vertigo?
vertigo triggered by change in head position - rolling over bed or gazing upwards
nausea
each episode : 10-20 seconds
positive dix-hallpike manoeuvre
no hearing loss/tinnitus.
what is the dix hallpike manoeuvre?
patient sits upright on a examination couch head turned 45 degrees.
support pt head to stay in 45 degree but rapidly lower pt back until head hanging off end of couch 20-30 degrees
hold pt head still turned 45 degree to 1 side and extended 20-30 degrees below level of couch.
watch eyes for 30-60 seconds - look for nystagmus.
repeat test with head turned other way in other direction.
will trigger other sx of vertigo.
rotational beats of nystagmus towards affected ear. (clockwise with left ear and anti for right) (ROTARY NYSTAGMUS)
how to get symptomatic relief from bppv?
epley manoeuvre
vestibular rehab - brandt-daroff exercises
betahistine - limited value
recurrence of bppv
sx 3-5 yrs after diagnosis
what is the epley manoeuvre?
used to tx bppv.
move crystals in semicircular canal into a position that dont disrupt endolymph flow.
do dix-hallpike : pt upright head rotated 45 to lying position, head extended off bed. rotate pts head 90 degrees past central position.
get pt to roll onto side so head rotates further 90 degrees in same direction.
get pt sit up sideways with legs off side of couch.
position head in central position with neck flexed 45 degrees, with chin towards the chest.
at each stage, support pts head in place for 30 seconds and wait for any nystagmus or dizziness to settle.
what are brandt-daroff exercises?
do at home to improve sx of bppv .
sit on end of bed lie sideways, from 1 side to other, while rotating the head slightly to face the ceiling.
What is a TIA?
brief period of neurological deficit due to vascular cause - last less than 1 hr.
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
clinical features of tia
similar to stroke : sudden onset, focal neurological deficit. but dont persist. typically resolve within 1 hr
features:
- unilateral weakness or sensory loss
-aphasia or dysarthria
-ataxia, vertigo, loss of balance
- visual problems: sudden transient loss of vision in 1 eye (amaurosis fugax), diplopia, homonymous hemianopia
typical tia mimics that need excluding
hypoglycaemia
intracranial haemorrhage - if on anticoagulant or with similar rf admit for urgent imagine to exclude haemorrhage.
pt with acute focal neuroloigcal sx that resolve completely within 24 hrs of onset. what should i do?
give aspirin 300mg immediately
assess urgently with 24 hrs by stroke specialist
imaging for tia
ct only when clinical suspicion of an alternative diagnosis that ct can detect - ie haemorrhage concern
MRI - diffusion weight and blood-sensitive - determine territory of ischaemia, detect haemorrhage or alternative pathology - do same day
how would you manage tia?
Medication:
- antiplatelet therapy - as long as no CI or high risk of bleeding
- within 24 hours of onset:
- clopidogrel - initial 300mg then 75mg od + aspirin initial dose 300mg then 75mg od for 21 days - followed by monotherapy with clopidogrel 75mg od
if not appropriate for dapt:
- clopidogrel 300mg loading dose then 75mg od
ppi considered for dapt.
lipid modification: high intensity statin like atorvastatin 20-80mg daily - reduce non-hdl cholestrol by over 40%
if a patient has af and just had a tia what should happen?
give anticoagulation as soon as intracranial haemorrhage excluded
carotid imaging for tia
benefit
what might you find
what would you do ?
atherosclerosis in carotid artery might be emboli source in some pts.
carotid duplex ultrasound or ct angiography/mr angiography.
carotid endarterectomy - if pt suffered stroke/tia in carotid territory and isnt severely disabled.
if stenosis over 50%
perform asap within 7 days
urinary incontinence risk factors
elderly female
advancing age
previous pregnancy and childbirth
high bmi
hysterectomy
fhx
postmenopause
pelvic organ prolapse
pelvic floor surgery
ms - neuro conditions
cognitive impairement and dementia
classifications of urinary incontinence
overactive bladder/urge : detrusor activity - urge to urinate quickly then uncontrollable leakage range from few drops to complete empty.
stress incontinence: cough or laugh small leak
mixed: urge and stress
overflow: bladder outlet obstruction like prostate enlargement
functional incontinence: comorbid physical condition. dementia,sedative meds, injury/illness
stress incontinence happens due to weakness of what?
pelvic floor and sphincter muscles - urine can leak at times of increased pressure on bladder
overflow incontinence happens when
what testing to do
chronic urinary retention due to obstruction to outflow of urine.
anticholinergic meds
fibroids
pelvic tumours
neuro conditions: ms, diabetic neuropathy, spinal cord injuries.
do urodynamic testing
assessing for urinary incontinence
take history.
assess lifestyle: caffeine,alcohol, meds, bmi
severity: frequency of urination/incontinence, nighttime urination, pads and clothing changes
assess pelvic tone and examine to pelvic organ prolapse,atrophic vaginitis, urethral diverticulum, pelvic masses
ask for pt to cough – watch for leakage from urethra
strength of pelvic muscle contraction assessed during bimanual examination - ask women to squeeze against examining fingers.
when i measure strength of pelvic muscle contractions, i do what exam , how do i do it and how is it graded?
bimanual exam
woman squeeze against examining fingers.
modified oxford grading:
0 - no contraction
1 - faint
2 - weak
3 - moderate with some resistance
4 - good contraction with resistance
5 - strong contraction, firm squeeze, draw inwards
ix for urinary incontinence
bladder diaries - min 3 days
vaginal exam: exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (kegel)
urine dip and culture
urodynamic studies
what are urodynamic studies?
rules
measure urge incontinence not responding to 1st line medical tx, difficulties urinating, urinary retention, previous surgery or unclear diagnosis.
pts stop taking anticholinergic and bladder related meds 5 days before test.
thin catheter into bladder and another into rectum. measure pressure in bladder and rectum and compare. bladder fill with liquid then measure:
- cystometry - destrusor muscle contraction and pressure
- uroflowmetry - flow rate measured
-leak point pressure- what point bladder pressure means leakage of urinel. get pt to cough move or jump when bladder filled to diff levels. stress incontinence
-post void residual bladder vol - incomplete emptying of bladder testing
-video urodynamic testing- fill bladder with contrast. take x ray image as bladder emptied.
how would you manage stress predominant urinary incontinence?
pelvic floor muscle training - min 8 contractions 3 times per day for min 3 months.
surgery: retropubic mid-urethral tape procedures
duloxetine - if women declines surgery : combined noradrenaline and serotonin reuptake inhibitor.
weight loss avoid caffeine diuretics or overfilling bladder or fluid intake.
what is duloxetine
moa
SNRI antidepressant
combined noradrenaline and serotonin reuptake inhibitor
increased synaptic conc of noradrenaline and serotonin within pudendal nerve = increased stimulation of urethral striated muscles within sphincter = enhanced contraction.
how would you manage urge predominant incontinence?
bladder retraining - lasts for min 6 weeks - increase gradually intervals between voiding
bladder stabilising drugs: antimuscarinics - 1st line : oxybutinin , tolterodine (both immediate release) or darifenacin (once daily prep)
immediate release oxybutynin avoid in fraily older woman
mirabegron - beta 3 agonist - anticholinergci se in fraily elderly patients
botulinum toxin type a - injection to bladder wall
urinary diversion - redirect urinary flow to urostomy on abdo
augmentation cystoplasty - bowel tissue to enlarge bladder
percutaneous sacral nerve stimulation - implant device in back that stimulates sacral nerves.
what anticholinergic side effects will mirabegron give in frail elderly patients?
who is it cid in
how does it work?
cognitive decline
memory problems
worsening dementia.
used as alternative for urge iwth less anticholinergic burden.
uncontrolled htn - cid;
beta 3 agonist - stimulatres sns = raised bp. = hypertensive crisis = increased tia/stroke risk.
