Geri's / GP / General med stuff you forget Flashcards
Lewy Body dementia presentation and treatment
Fluctuating cognitive impairment, visual hallucinations (not unpleasent), later on there can be Parkinsonism.
Tx similar to AD (Acetylcholinesterase inhibitors and memantine depending on stages). Antipsychotics should be avoided as precipitate parkinsonism (BDZs better)
How to differentiate PD from Dw/LB?
Lewy body dementia is more likely if dementia starts before or within 1 year of the onset of the parkinsonian symptoms. LBD also commonly causes visual hallucinations of people. Also a poor response to co-careldopa is a clue
Parkinson’s disease dementia is more likely if dementia occurs around 4-5 years after motor symptoms (but at the very least should be 1 year after).
What tool can be used to assess malnourishment/those at risk of becoming malnourished?
MUST
Measure BMI
note percentage Unplanned weight loss
establish acute disease affect and score.
2+ = immediate care with dietetic input.
What is the STOPP tool?
Screening tool of older person’s prescriptions
Identifies medications where the risk outweighs the therapeutic benefits in certain conditions
What is the START tool?
Screening Tool to Alert doctors to the Right Treatment. It looks at which medications should be used for certain conditions in patients 65 years or older.
What is frailty?
a clinical state of vulnerability, related to diminishing strength, natural ageing and a decline in physiological reserve. Resulting in an inherent risk of adverse clinical outcomes from minor stressors or challenges
What are the 4 syndromes in frailty?
(My Pa Cant Drive)
Malnutrition
Physical impairment
Cognitive impairment
Depression
What does the Fried Model suggest the frailty phenotype is?
3 or more of following:
* Unintentional weight loss
* Weakness (poor grip strength)
* Self-reported exhaustion
* Slow walking speed
* Low level of physical activity
What is Rockwood clinical frailty score?
9 point score that summarises general level of frailty.
You just score 1-9 based on clinical judgement
What is frailty index
A count of health deficits, the more deficits the more frail and greater risk of death.
Number of deficits an individual has / total number of deficits considered
Very fit <0.09, mild frailty 0.27, severely frail 0.42.
5 physiological marker’s of frailty
- Increased inflammation – chronic inflammation due to dysregulation of multiple systems
- Elevated insulin and glucose levels in fasting states
- Low albumin
- Raised D-dimer
- Low vitamin D levels.
Some interventions for frailty
Vit D, diet, exercise (PT input), reduce polypharmacy, home adaptations, manage comorbidities
Prevent Cx
CGA is gold standard.
Name intrinsic and extrinsic RF for falls
- Intrinsic – female, Cognitive decline, visual deficit, muscle weakness, causes of syncope
- Extrinsic – polypharmacy, bifocal glasses, walking aids, footwear, home hazards
What is the triad of rhabdomyolysis symptoms and how is it treated?
myalgia, weakness, and myoglobinuria (tea-coloured urine).
IV fluids, dialysis if severe.
What are the 3 main categories of syncope (and 3 subtypes of reflex syncope)
Cardiac - arrhythmias, structural heart disease
Othostatic hypotension
Reflex syncope (NMRS)
- Vasovagal - mediated by emotiona stress or orthostatic stress
- Situational - post-prandial, cough/sneeze, postmicturition, playing wind instrument
- Carotid sinus syndrome
Describe pathophysiology of carotid sinus syndrome (CSS)/carotid sinus hypersensitivity and why it is more common in the elderly
Any pressure, e.g. neck turning, tight collars, shaving, leads to stimulation of the carotid sinus. The brain thinks we have hypertension causing a fall in HR and BP (vasodilation)
More common in elderly as the carotid baroreceptors get more sensitive as we age.
State 5 symptoms and 3 signs that indicate a cardiac cause of syncope
Syncope on exertion
If LOC occurs while supine (rules out postural)
Collateral cardiac Sx - palpitations/chest pain
PMHx of heart disease
FHx of sudden death
Signs - raised JVP, 3rd/4th heart sounds, pulmonary oedema.
Name 2 drugs that can help treat orthostatic hypotension
Fludrocortisone - aldosterone agonist
Midodrine - alpha agonist that increases BP
Define orthostatic hypotension and name 5 causes
Diagnosed as systolic BP drop of >20mmHg or diastolic BP drop of 10mmHg within 3 mins of standing. Also, if systolic drops <90 from any starting point.
Many conditions can cause it:
- Dehydration (fever, vomiting, diarrhoea, blood loss)
- Cardiac - bradycardia, AS, HF (heart cannot compensate for postural drop)
- Endocrine - Adrenal insufficiency (addison’s, less adrenal hormones = hypotension), DM (autonomic neuropathy)
- Neurological - PD, MSA, dementia (any autonomic neuropathy)
- Drugs - Tamsulosin/alpha blocker causes dilation of venous vessels lowering BP), diuretics, TCAs.
What is Barthel index?
A scale covering 10 basic ADLs used to establish degree of dependency. Usually out of 100, modified is /20.
Doesnt detect issues in mental functioning
What is Berg balance test?
Covers 14 everyday tasks, more basic than ADLs used in Barthel (e.g. transfer, sitting, standing etc.)
Does not assess gait
What is NEADL?
Nottingham extended ADL
Assess 22 instrumental ADLs (more complicated ADLs like “travel on public transport”).
Goes beyond the ceiling that can happen in BI.
What is Timed up and go test
It assess frailty/functioning
Sit, walk 3m, turn around and comeback and sit.
Tests transferring, static balance, dynamic balance, gait and cognition can all adversely impact upon the timed-up-and-go test.
What is normal AMT score?
8 or above (8, 9, 10)
It gives a quick overview of cognitive function - memory and orientation.
What is MOCA?
Montreal Cognitive Assessment
A screening tool for MCI. Useful in early AD.
Discriminates between normal cognition and MCI, but less good at getting severe CI.
Describe aetiology of pressure sores (acquired & inherited)
Acquired if they occur within a care facility
Inherited if pt moves into a facility with ulcer already present
Ulcers usually multifactorial
- Limited movement
- Sensory impairment
- Malnutrition/dehydration
- Obesity
- CI
- Urinary/faecal incontinence
- reduced tissue perfusion
What are the stages of pressure ulcers (1 to 4) and there Tx
Stage 1 - non-blanching erythema (intact skin). May feel warm and painful.
Stage 2 - partial thickness skin loss (epidermis/dermis) without slough. It is a superficial ulcer.
Stage 3 - full thickness skin loss, with loss of SC down to (but not through) underlying fascia. Slough or eschar may be present
Stage 4 - full thickness tissue loss w/ exposed bone/tendon/muscle.
Tx with prevention mainly (SSKIN - support surface (cushions), skin assessment, keep moving, incontinence/moisture, Nutrition and hydration)
Hydrocolloid dressings/hydrogels help healing. Avoid soaps.
Topical antimicrobial therapy (silver, honey, iodine) only when signs of local infection. Systemic abx if systemic sepsis or osteomyelitis.
What Ix for pressure ulcers?
Waterlow/Braden tools
Wound swabs not routine as most are colonised w/ bacteria. As such, decision to Tx based on clinical basis (e.g. surrounding cellulitis)
How is constipation in the elderly treated?
1st line lifestyle (oral fluid/fibre)
1st line medication = docusate (stimulant and softening properties)
May add macrogol (osmotic/softener)
Describe stimulant, osmotic, bulking laxatives indication/CI and SE
Stimulant - senna, danthron (palliative). Useful in older patient w/ normal stool but reduced motility. Increased motility can cause cramps.
Osmotic - lactulose, macrogols. Useful for hard stools/painful defacation. Require adequate oral intake and can cause dehydration.
Bulking - fybogel, methylcellulose. Good for inadequate fibre/small hard stools. Can cause abdo distension.
What are the 4 components to ageing
- A universal process – occurs in all individuals of the same species
- Intrinsic – endogenous factors predisposing to particular patterns of ageing
- Progressive – occurring throughout life and present to a lesser degree in younger adults
- Deleterious – changes to the individual associated with ageing must be “bad”.
What is primary and secondary ageing
Primary ageing is the interplay of intrinsic factors, such as the genetic makeup of an individual, and extrinsic factors, such as smoking, diet and exposure to UV light.
Secondary ageing is the adaptive response to primary ageing, which may not always be negative. An example would be writing things down due to a poor memory.
Physiology of ageing - what happens to:
A) Body fat and water distribution
B) Bone and muscle mass, and why
C) Immune system
D) CV system
A) Proportion fat increases, becomes central. Decrease total body water (cell shrinkage - ICF loss).
B) Reduced due to disuse atrophy, reduced testosterone/GH, impaired protein synthesis
C) Immunosenescence - B cell numbers are preserved but decreased antibody production (increased autoantibody). T cell numbers decrease.
D) Reduced elastin, increase collagen.
