Geriatric Flashcards
1
Q
Major NCD prevalence
A
1-2% in 65yo (2/10)
30% in 85yo (1/3)
F > M
2
Q
Global deterioration scale (1-7)
A
Mild = 3 Major = 4
3
Q
Mild NCD prevalence
A
10-20% in 65yo (1-2/10)
4
Q
Mild NCD conversion rates
A
5-10% / year to AD
75-80% / 10 years
BUT
25-30% RETURN TO NORMAL
5
Q
Mild NCD treatment
A
ACEi not helpful
TREAT HYPERTENSION (target < 140mmHg systolic) Healthy lifestyle
Treat depression: SSRI tx > 4 years can delay progression to AD by 3 years
6
Q
Major NCD distribution
A
AD 50-60% Vascular 15-30% Lewy body 10-25% Mixed 10% FTD 5%
7
Q
Normal pressure hydrocephalus
A
WACKY, WOBBLY, WET
Cognitive decline, gait disturbance, urinary incontinence
8
Q
Pseudodementia
A
Secondary DD, hospitalization, fecaloma, sensory deficit
NOT IMMOBILIZATION
Abrupt, symptoms progress rapidly Distressed about symptoms Worst in the morning Improves with sleep deprivation "I don't know" instead of confabulation
9
Q
Ribot’s Law
A
Gradient to retrograde amnesia
recent > remote memories
10
Q
Proteinopathies
A
AD = amyloid plaque, neurofibrillary tangles, TAU
Pugilistica (secondary TBI) = amyloid plaque, neurofibrillary tangles, TAU
LBD/PD = alpha synuclein
FTD (Pick) = TAU, TDP-34, ubiquitine
11
Q
Which dementia aetiologies don’t have neurofibrillary tangles?
A
Those secondary to repeated cerebral insult
- vascular
- due to substance
- due to HIV
- due to other medical diagnosis (infection)
12
Q
Cortical dementias
A
Alzheimer’s
FTD (Pick’s)
CJD
AMNESIA (recall + recog) AGNOSIA APRAXIA APHASIA SEIZURES COUNTING (EARLY)
13
Q
Subcortical dementias
A
Parkinson's dementia Huntington's dementia Wilson's dementia HIV dementia NPH dementia
Depletion Depression Dysexecutive Delay Dysmnesia (recall only) Dysarthria Dystonia Chorea Slowing Counting (LATE)
14
Q
Mixte dementias (cortical + subcortical)
A
Vascular dementia
LBD
Alcohol dementia
15
Q
Indications for genetic testing
A
< 65 yo + family history
6-7% of cases
PSEN1 = ch 14 (30-70%)
PSEN2 = ch 1 (< 5%)
APP = ch 21 (10-15%)
16
Q
Mini cog
A
Repeat 3 words
Clock
Recall 3 words
0/3 = positive 1-2/3 = positive only if abnormal clock
17
Q
MMSE
A
Ceiling (not sensitive if high education) + floor (not specific if very low score) effect
Cutoff 24/30
Sensitivity 82%
Specificity 87%
18
Q
MOCA
A
Extra point if schooling < 13 years
Cutoff 26/30
More SENSITIVE than MMSE
19
Q
What does FMRI measure?
A
OXYGENATION
20
Q
What does PET measure?
A
Glucose metabolism
NO DECREASE IN THALAMIC TUMOR
21
Q
What is CT scan better for?
A
Acute bleed
Calcium
Bone
22
Q
Test for frontal function?
A
LURIA SERIE
23
Q
Major NCD due to AD criteria?
A
At least 2 cognitive domains
24
Q
Mild NCD due to AD criteria?
A
At least 1 domain
25
Alzheimer's dementia prevalence
10% in 70yo
| 20% in > 70yo
26
Risk factors for AD
```
Age
Women
Low education
Depression
Increased homocysteine
Increased estrogen
Trisomy 21
```
27
Protective factors for AD
Education (> 15 years)
APO-E2
Blood pressure (< 140mmHg systolic)
28
Genes involved in late AD
APO-E4 on CHROMOSOME 19
E4/E4 RR 8-11
E4/E3-2 RR 3
SORL1
29
Extracellular pathology in AD
AMYLOID PLAQUES (beta 42)
30
Intracellular pathology AD
NEUROFIBRILLARY TANGLES (tau)
31
Neurotransmitters in AD
LOW ACETYLCHOLINE (low AChE, high BuChe)
LOW NOREPINEPHRINE
LOW SOMATOSTATIN
LOW CORTICOTROPINE
32
Most common hallucination in AD?
Visual
33
Mechanisms of vascular dementia
1. Multiple cortical strokes
2. Strategic stroke (anterior cerebral artery, thalamus, parietal lobe, singular gyrus)
3. Lacunar strokes (small vessel disease)
34
Vascular dementia
Decreased complex attention
Decreased executive functioning
STEPWISE DECLINE rather than insidious
Risk factors:
Cerebral amyloid antipathy
CADASIL
35
Binswanger
```
Type of VASCULAR dementia
Slowly progressing
SUBCORTICAL vascular encephalopathy
Chronic hypertension
Pseudobulbar, parkinsonian, pyramidal sx
```
36
Lewy body dementia symptoms
CORE SX
- fluctuating cognition
- repeated visual hallucinations
- spontaneous Parkinsonism (more often symmetrical)
SUGGESTIVE SX
- REM sleep trouble
- Severe hypersensitivity to antipsychotics
37
Lewy body dementia criteria
Probable = 2 core OR 1 core + 1 suggestive
Possible = 1 core OR many suggestive
38
Other diagnostic elements of Lewy body dementia
Fall/syncope
Autonomic dysfunction
Delusions
Depression
Decreased dopamine in the basal ganglia
OCCIPITAL HYPOMETABOLISM ON PET
Fully formed "little" people or animals (lilliputian)
39
Parkinson Plus syndromes
1. Corticobasal degenerescence
2. Supranuclear progressive paralysis
3. Multi-system atrophy
4. Lewy body dementia
40
Corticobasal degenerescence
Strange limb
Fronto-parietal symptoms
Resistant to L-dopa
Asymmetrical rigidity
41
Supranuclear progressive paralysis
```
Symmetric Parkinson
Supranuclear paralysis (can't look up)
Postural problems
Moderate response to L-dopa
TAU disease
```
HUMMINGBIRD SIGN on imaging
42
Multi-system atrophy
```
Autonomic dysfunction
Urinary incontinence
Orthostatic hypotension
Cerebella syndrome
Decreased sensitivity to L-dopa
```
43
Frontotemporal dementia
Suspect if young (average age 56 yo)
Life expectancy 3-14 years after diagnosis
POST-SYNAPTIC SEROTONIN DEFICIT
Genes = TAU/TDP34
Chromosomes 9 & 17
Early personality & language changes
Preserved memory and visuospatial function
44
Frontotemporal dementia genes?
10-15% autosomal DOMINANT
MAPT
Granulin
C9orf72
45
Frontotemporal dementia types?
Behavioural variant (50%)
Language variant aka primary progressive aphasia (50%)
a) semantic
b) agrammatical/non-fluent
c) logopenic
46
FTD behavioral variant
M >>
BILATERAL ORBITOFRONTAL
At least 3 criteria
- disinhibition
- apathy
- lack of empathy
- stereotyped movements
- hyperorality
Pick's disease - 40% familial
47
FTD language variant
a) Semantic
- M >>
- LEFT TEMPORAL LOBE atrophy
- trouble with naming + understanding
b) Agrammatical/non-fluent
- F >
- LEFT POSTERIOR FRONTOTEMPORAL
- trouble with naming + understanding
- lacks spontaneity in speech
c) Logopenic
- associated with Alzheimer's
48
NCD secondary TBI treatment
Apathy: modafinil, psychostimulants, ADs that increase NE
Aggressivity: propranolol, pindolol, epival, tegretol
NOT ENOUGH EVIDENCE FOR NEUROLEPTICS
49
Risk factors for psych issues following TBI
Long period unconscious
Long period amnesia
Older age
50
CJD
CORTICAL
Prion disease
Classical pathology triad
1. Spongiform vacuolisation
2. Neuronal loss
3. Astrocyte proliferation
Predominant cerebellar and motor symptoms
- myoclonus
- choreoathetoid movements
- ataxia
- ballistic movements
Anomaly in FLAIR/DWI MRI = multifocal hyper intensities of cortical grey matter ("cortical ribbon" sign)
Protein TAU or 14-3-3 in CSF
EEG = diffuse slowing, typical periodic sharp wave complexes (triphasic waves)
51
Huntington Chorea
Mutation on CHROMOSOME 4
Gene = IT15
Trinucleotide repetition CAG (cytosine-adenosine-guanine) > 36-40
of repeats correlates with cognitive symptoms but NOT WITH PSYCHIATRIC SYMPTOMS
Triad = MOTOR, PSYCHIATRIC, COGNITIVE
Atrophy of CAUDATE & lenticular nuclei (especially putamen then globus pallidus
52
NNT for ACEi?
4-13
53
2 types of cholinesterase?
Acetylcholinesterase (in synaptic cleft)
| Butyrylcholinesterase
54
ACEi not indicated for?
Mild NCD
FTD
Being in a CHSLD is NOT a reason to stop treatment
55
RAMQ coverage for ACEi?
For MMSE 10-26
| Stops if decrease of > 3 points in 6 months of tx
56
Contra-indications for ACEi?
Bundle branch block
Fascicular block
Interaction with OXYBUTYRIN (decreased efficacy)
DO ECG BEFORE STARTING
57
ACEi side effects?
```
GI (increased ulcer risk)
Insomnia
NIGHTMARES (especially Donepezil)
Bradycardia (via VAGAL nerve stimulation)
Syncope
Urinary incontinence
Neuromuscular
```
58
Aricept (Donepezil)
Selective inh. acetylcholinesterase
LIVER (2D6/3A4)
Half life = 70 hours
10mg DIE
59
Galantamine (Reminyl)
Inh. acetylcholinesterase + STIMULATES NICOTINIC
Liver + kidney
Half-life = 7-8 hours
16-24mg (DIE or BID dosing)
60
Rivastigmine (Exelon)
Inh. BOTH acetylcholinesterase + butyrylcholinesterase
Oral or transdermal
3-6mg BID
5-10mg patch
TAKE WITH FOOD
KIDNEYS
First choice for Lewy body dementia
61
Memantine (Ebixa)
ANTAGONIST NMDA RECEPTORS
(glutamate in excess in Alzheimer's)
10mg BID
Side effects
Dizziness, headache, constipation
Contraindicated in RENAL FAILURE
RAMQ covers if MMSE 2-14 and NOT in CHSLD
RAMQ does NOT cover combination with ACEi
62
FTD treatment
NOT ACEi
Trazodone (irritability)
Paxil
63
Lewy body dementia treatment
RIVASTIGMINE which can decrease hallucinations
Avoid APs but if need SEROQUEL or CLOZAPINE
64
Parkinson'd dementia treatment
CLOZAPINE
65
Vascular dementia treatment
Not enough evidence for ACEi but if yes then Donepezil or Galantamine
66
BPSD
in > 90% patient with dementia
Only APs approved to treat are:
Risperdal
Abilify
Zyprexa
PRNs:
Trazodone
Ativan
Symptoms that don't respond well to Rx:
- apathy (anterior cingulate)
- disinhibition
- wandering ("errance")
- verbal
Try to decrease or stop Rx every 3-6 months
67
What is the #1 cause of psychotic symptoms in elderly?
DEMENTIA
68
What medication is NOT RECOMMENDED in BPSD
EPIVAL
69
Black box warning in elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs
NNH = 100 (1 extra death per 100 patients)
RR death 1.6-1.7 (1% higher than placebo over 10 weeks)
RR stroke 10 (@ 1 week)
RR fall 1.7
RR pneumonia 4.5
70
DICE approach to non-pharmacological interventions
Describe
Investigate
Create a plan
Evaluate if working
71
Delirium criteria
```
ATTENTION
AWARENESS
+
1 OTHER COGNITIVE DOMAIN
+
Direct physiological consequence of illness/substance
```
72
Delirium types
Hyperactive 30%
Hypoactive 24%
Mixed 46%
73
What medication to give ventilated patients to prevent delirium?
PRECEDEX
| dexmedetomidine
74
Risk factors for delirium?
```
>65yo
Male
Cognitive deficit
Delirium hx
Sensory deficit
Immobilization
Malnutrition
Medical co-morbidity
```
75
Delirium prevalence?
1-2% in general population
| 10-30% in hospitalized population
76
Most implicated neurotransmitter in delirium?
ACETYLCHOLINE (decreased)
77
Most implicated brain region in delirium?
RETICULAR FORMATION (regulates attention and arousal)
Main pathway = dorsal tegmental (reticular formation and thalamus)
78
EEG in delirium
Generalized slowing (theta & delta)
79
Increased mortality in the year following delirium dx by how much?
40-50%
80
Pharmacokinetic changes in elderly
NO CHANGE IN ABSORPTION
Decreased gastric motility
Increased gastric pH
Increased fat stores (less liposoluble Rx)
Increased volume of distribution (increased 1/2 life)
Decreased CYP metabolism by 2-3x (linear with age, down first pass)
GLYCUROCONJUGAISON SAME (2nd pass)
Decreased albumin so increased free Rx
Decreased body water volume (more hypo soluble Rx)
81
Neurobiology changes in elderly
Decreased processing speed & motor speed
Decreased norepinephrine in CNS
Increased serotonin & MAO in brain
82
Suicide in the elderly
High res despite low rates of depression, due to solitude
DEMENTIA IS NOT A RISK FACTOR
Less explicit signs
Higher lethality (less history of past attempts)
Less contact with services
83
Emotions in the elderly
MORE POSITIVE EMOTIONS
| Less negative emotions
84
Geriatric depression scale
30 Y or N questions about how they feel THAT DAY/OVER THE LAST WEEK
Target: healthy, medically ill, mild to moderate cognitive impairment
92% sensitivity
89% specificity
Cutoff is 10/30
(20 = severe)
85
Anticholinergic toxicity
```
Flushing, dry skin
Mydriasis
Loss of accommodation
Tachycardia
Hypertension
Fever
Urinary retention
Functional ileus
Tremor
Myoclonic jerking
Altered mental status
```
86
Rx causing delirium
```
Psychoactive medications
Anticholinergic medications (MOST COMMON as per K&S)
Sedative/hypnotics
Meperidine (opioids)
Corticosteroids
```
87
Which opioid is worst for delirium?
MEPERIDINE (demerol)
88
Delirium treatment
PHARMACOTHERAPY IS OFF-LABEL
Haldol (least anti-cholinergic)
Second-generation antipsychotic
89
Which genetic syndrome common in FTD?
KLUVER-BUCY
| no hypersomnia unlike Kleine-Levin...think they have inappropriate sexual behaviour so they are UP ALL NIGHT
90
Which BPSD symptom responds best to antipsychotics?
AGGRESSION/agitation
91
Most common BPSD?
APATHY (72%)
92
Which dementia has NO TANGLES?
VASCULAR dementia
93
What percentage of dementias are reversible?
15%!
| Hypothyroid, tumor, NPH, B12
94
Memory centres in brain?
Medial temporal lobe:
- hippocampus
- amygdala
95
Most commonly reported elder abuse in Canada
FINANCIAL (according to K&S)
96
Late-onset schizophrenia
Good response to antipsychotics, use lower doses
Generally negative symptoms are rarer in late-onset
Paranoid most common
97
Schizophrenia in >65yo
20% have no active symptoms by 65
98
Pharmacokinetics in elderly
```
Absorption largely unchanged
No change in LFTs (reflect damage, not liver function)
Unchanged conjugation (phase 2)
Decreased phase 1 (oxidation, reduction, hydrolysis)
```
