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DMH Prep > Geriatric > Flashcards

Geriatric Flashcards

1
Q

What are the causes for delirium as per the DIMTOPO mnemonic?

A

Drugs (remember calcium channel blockers)
Infection
Metabolic
Trauma
Oxygen deficits
Post-ictal
Other

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2
Q

What are the risk factors for delirium (8)?

A

Advanced age >65
Dementia
Cognitive impairment
Previous history of delirium
Depression
Alcohol Use
Severe medical illness
Recent surgery

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3
Q

What are some of the complications associated with delirium (7)?

A

Aspiration pneumonia
Dementia
Pressure sores
Weakness, decreased mobility, decreased function, contractures
Falls and combative behavior leading to injuries and fractures
Malnutrition, fluid and electrolyte imbalance
Increased mortality

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4
Q

Differential diagnosis for delirium (4)?

A

Dementia
Schizophrenia
Depression
Factitious disorder and malingering

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5
Q

What are the delirium specifiers (3)?

A

Acute vs persistent

Hyperactive vs hypoactive vs mixed

Causes - substance intoxication, substance withdrawal, medication induced, acute medical conditions, multiple causes

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6
Q

What are the antipsychotics of choice in delirium?

A

Low doses of risperidone and haloperidol.
High risk of EPSEs in delirious patients.

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7
Q

What are the DSM 5 diagnostic criteria for delirium (5)?

A

A - disturbance in attantion and awareness

B - disturbance develops over a short period of time, represents a change from baseline attention and awareness, tends to fluctuate in severity during the course of the day

C - additional disturbance in cognition

D - disturbances in A and C are not better explained by another preexisting, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as a coma

E - evidence from the history, physical exam, lab findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal

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8
Q

What are the investigations recommended in delirium?

A

FBC
Renal profile
LFT
CMP
Blood glucose
ABG
TSH
Septic screen - urine distix and UMCS if indicated, chest Xray, blood culture
ECG
Malaria films
HIV
Syphilis
LP, EEG, CT brain

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9
Q

Which standardized assessment tool is currently used for the examination of patients with delirium?

A

CAM - confusion assessment method
This method uses another tool as an entry requirement to the CAM - the RASS which ranks agitation and possibility for sedation

Feature 1 - acute onset or fluctuating course
Feature 2 - inattention
Feature 3 - altered level of consciousness as per the RASS
Feature 4 - disorganized thinking

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10
Q

What are the key principles in pharmacological treatment of delirium?

A

Keep use of sedatives and antipsychotics to a minimum
Use one drug at a time
Adjust the doses according to age, body size, degree of agitation
Titrate doses to effect
Use small doses regularly rather than larger doses less frequently
Review at least every 24 hours
Increase the scheduled doses after 24 hours if regular PRN doses are required
Reduce ASAP
Develop a discharge plan if the medication has not been stopped by the time of discharge

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11
Q

What is considered the first line antipsychotic of choice for use in delirium?

A

Haloperidol

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12
Q

In which two neurocognitive disorders should haloperidol be avoided?

A

Lewy Body Dementia and Parkinson’s disease

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13
Q

Which major complication is associated with use of ALL of the antipsychotics in patients with dementia?

A

Stroke

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14
Q

Which lab values are important to monitor when using Amisupride in a delirious patient and why?

A

Creatinine and eGFR - amisulpride is almost entirely excreted by the kidney

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15
Q

Which two antipsychotic choices are associated with poorer effect in an older age group >70

A

Olanzapine and Risperidone

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16
Q

Which agent is considered the second choice to Haloperidol in the treatment of delirium with antipsychotics?

A

Quetiapine

17
Q

Which four causes of delirium justify the use of benzodiazepines?

A

Alcohol withdrawal
Sedative/hypnotic withdrawal
Parkinson’s disease
Neuroleptic malignant syndrome

18
Q

What does the MMSE consist of?

A
  1. ORIETATION
    What is the date, month and year
    What town, province and hospital are we
  2. REGISTRATION
    Name three basic objects
  3. ATTENTION AND CALCULATION
    Count backwards in 7s from 100
    Spell the word world backwards
  4. RECALL
    Name three objects above 5 minutes later than they were originally named
  5. LANGUAGE
    Name a pen and a clock
    Say No ifs ands or buts about it
    Follow a 3 step command
  6. EXECUTIVE FUNCTION
    Close your eyes
    Write a sentence
    Copy a design
19
Q

What are the 6 cognitive domains?

A

Complex attention
Executive function
Learning and memory
Language
Perceptual Motor
Social cognition

20
Q

What is the basic mechanism of causing impairment in memory and cognition in older age?

A

Deficiency in the acetylcholine level in the brain.

This results in a reduction in the cholinergic neurotransmission.

There is excessive NMDA receptor activity which in turn causes excitotoxicity and neuronal death and the neuronal death is responsible for impairment in memory and cognition.

21
Q

What are two examples of Cholinesterase inhibitors?

A

Donepezil - only works on acetylcholinesterase and not butyl. First line in AD

Rivastigmine - this is the only one of the three that shows significant inhibition of both butyl cholinesterase and acetylcholinesterase.
Can be used in AD, PD, mild neurocognitive impairment and memory disorders in other conditions.

Galantamine
Of note, this one also modulates the nicotinic receptors which may in turn enhance the actions of acetylcholine.

22
Q

What is an example of a NMDA (glutamate) receptor antagonist?

A

Memantine

Some indications include AD, mild cognitive impairment, memory disorders, chronic pain.

23
Q

What are some of the key side effects of cholinesterase inhibitors and separate into the more mild and severe

A

Milder - nausea, vomiting and diarrhea

Severe - bradycardia, significant weight loss and lack of appetite

24
Q

Briefly describe the MOA of a NMDA receptor antagonist

A

Glutamate in the synaptic cleft causes an influx of calcium into the cell when it stimulates the glutamate receptor.
When there is too much glutamate in the synaptic cleft, this causes too much calcium to enter the cell which causes cell rupture and death.
The NMDA receptor antagonist blocks this receptor.

25
Q

What are the common side effects of memantine?

A

Diarrhea, headache and insomnia

26
Q

Comment briefly on the MOA of cholinesterase inhibitors

A

Increased availability of ACh compensates in part for the degenerating cholinergic neurons in the neocortex that regulate memory

27
Q

Give a general description of the presentation of cortical dementias

A

Cerebral cortex is involved
Progressive deterioration of memory and higher-order cortical dysfunction that affects language (aphasia), motor activity (apraxia) and interpreting sensory stimuli (agnosia)

28
Q

Give a general description of the presentation of subcortical dementias

A

Involve the subcortical areas of the brain such as deep white matter, basal ganglia and thalamus

Typically involve slower speed and rigidity of thinking (bradyphrenia) and difficulty in retrieving stored memory (memory impairment is generally less severe), problem solving skills and personality changes (apathy, depression, anxiety).

29
Q

What are examples of cortical dementias

A

Alzheimer’s disease
Fronto-temporal dementia

30
Q

What are examples of subcortical dementias

A

Vascular dementia (deep white matter infarcts)
HIV dementia
Parkinson’s disease
Wilson’s disease

31
Q

What is a common form of dementia that has both cortical and subcortical involvement

A

Vascular dementia with multiple infarcts in many different brain areas
Lewy-body dementia

32
Q
A

DMH Prep (17 decks)

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