Geriatric Medicine

Question 1

main diff between dementia and delirium

other factors to suggest delirium

Answer 1

impairment of conscious level

other factors to suggest delirium:
- short hx
- Fluctuation of syms (worse at night, then periods of normality)
- Abnormal perception (illusions, hallucinations)
- Agitation, fear
Delusions

Question 2

pressure ulcers

• what scale?
• grading
• mx

Answer 2

· Waterlow scale screens for those at risk

NOTES
predispose to dev:
	- malnourishment
	- incontinence
	- lack of mobility
	- pain (leads to a reduction in mobility)

Grade Findings
1 Non-blanchable erythema of intact skin.
Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
2 Partial thickness skin loss involving epidermis or dermis, or both.
The ulcer is superficial and presents clinically as an abrasion or blister
3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss

Management

- a moist wound envt encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
- wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
- consider referral to the tissue viability nurse
- surgical debridement may be beneficial for selected wounds

Question 3

what drugs worsen symptoms in LB dementia

Answer 3

neuroleptics (can dev irreversible parkinsonism) - antipsychotics

Question 4

LB dementia

• pathology- dx
• mx

Answer 4

Pathological ft: alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

Diagnosis
• usually clinical
• single-photon emission computed tomography (SPECT): increasingly used (a DaTscan)
○ Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope.
○ sensitivity 90% with a specificity of 100%

Management
acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's.

Question 5

pick’s disease

Answer 5

• Characterised: personality change and impaired social conduct.
  
  • Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.

Focal gyral atrophy with a knife-blade appearance

Macroscopic changes: Atrophy of the frontal and temporal lobes

Microscopic changes include:-
	• Pick bodies - spherical aggregations of tau protein (silver-staining)
	• Gliosis
	• Neurofibrillary tangles
Senile plaques

Question 6

chronic progressive aphasia

• a type of ?
• fts

Answer 6

• non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.

frontotemporal lobar degeneration

Question 7

semantia dementia

• a type of
• fts

Answer 7

frontotemporal lobar degeneration

- fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. 
- Unlike in Alzheimer's memory is better for recent rather than remote events.

Question 8

· Pt w LB dementia: carbidopa-levodopa dose increased 2mos ago to target resting tremor + bradykinesia
Now having visual hallucinations, paranoid delusions, aggressive:

mx?

Answer 8

decrease dose

Question 9

vascular dementia

mx

Answer 9

tight control of vascular RF (to slow disease progression)

Question 10

alzheimer’s mx

Answer 10

Pharm

1. Mild-mod: acetylcholinesterase inh (donepezil, rivastigmine, galantamine)
2. Memantine (NMDA rec antagonist)

Memantine uses

- moderate AD who are intolerant/CI to acetylcholinesterase inhibitors
- Mod-severe: as an add-on drug to acetylcholinesterase inhibitors 
- monotherapy in severe Alzheimer's

Question 11

donepezil. what is it, SE, CI

Answer 11

Donepezil
acetylcholinesterase inh
• is relatively contraindicated in patients with bradycardia
• adverse effects include insomnia

Question 12

acetylcholinesterase inh (3)

Answer 12

donepezil, rivastigmine, galantamine)

Question 13

memantine what is it

Answer 13

NMDA rec antagonist

Question 14

pathology of AD

Answer 14

Pathological changes
• macroscopic: widespread cerebral atrophy, esp involving the cortex and hippocampus
• microscopic:
○ cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
○ hyperphosphorylation of the tau protein has been linked to AD
• biochemical
○ deficit of acetylcholine from damage to an ascending forebrain projection

Neurofibrillary tangles
• paired helical filaments are partly made from a protein called tau
• tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules
• in AD are tau proteins are excessively phosphorylated, impairing its function

Question 15

RF of AD

Answer 15

RF
	• increasing age
	• FHx of Alzheimer's disease
	• 5% inherited as an AD trait 
		○ mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
	• apoprotein E allele E4 - encodes a cholesterol transport protein
	• Caucasian ethnicity
Down's syndrome

Question 16

differentials (physical health) for dementia

Answer 16

• hypothyroidism, Addison’s
  
  • B12/folate/thiamine deficiency
  • syphilis
  • brain tumour
  • normal pressure hydrocephalus
  • subdural haematoma
  • depression
  • chronic drug use e.g. Alcohol, barbiturates

Question 17

causes of dementia (psych/neuro)

Answer 17

Common causes
	• Alzheimer's disease
	• cerebrovascular disease: multi-infarct dementia (c. 10-20%)
	• Lewy body dementia (c. 10-20%)
Rarer causes (c. 5% of cases)
	• Huntington's
	• CJD
	• Pick's disease (atrophy of frontal and temporal lobes)
HIV (50% of AIDS patients)