Geriatric medicine Flashcards
what are the side effects of donepezil, galantamine and rivastigmine?
diarrhoea, nausea and vomiting, excess salivation, urinary incontinence and bradycardia
how does lewy body dementia classically present?
REM sleep disorder, history of falls (secondary to motor problems) and hallucination
what cardiac investigation should be done before commencing a patient on an anticholinesterase inhibitor? what are the contraindication?
ECG
-prolonged QT interval, bradykinesia <50, second or third degree heart block
what are some aspects of non-pharmacological management of dementia patients?
psychoeducation/information giving, carer support, support groups and advance care planning
what is the classic triad of normal pressure hydrocephalus?
gait disturbance, dementia and urinary incontinence
what are the most common conditions leading to charles bonnet syndrome?
age related macular degeneration, cataract and glaucoma
What investigations are done for osteoporosis?
DEXA scan and calcium and vitamin D levels. (Women over 75 with fragility fractures have presumptive diagnosis of osteoporosis without need for DEXA scan)
What is the cut off T-score for osteoporosis?
-2.5
If a patient has severe osteoporosis which is not explained just by being post menopausal, what tests should be done?
Thyroid function, calcium, parathyroid, bone turnover markers. Also myeloma screen
What is first like management for osteoporosis?
Alendronate with vitamin D and calcium supplements
You want to start a patient on Adcal-D3 for bone protection but they cannot manage to swallow large tablets. What is an alternative?
Provide them with a dissolvable preparation of Adcal-D3 to improve compliance
What do different T scores suggest?
Greater than -1 = healthy bone
-1 to -2.5 = osteopenia
Less than -2.5 = osteoporosis
What is the AMTS?
Abbreviated mental test score is a ten point test to rapidly assess elderly patients for presence of cognitive impairment. A score of 6 or less suggests delirium or dementia
How should patinets be advised to take alendronate?
Administered once a week. Taken on an empty stomach while sat upright for thirty minutes with a full glass of water. Do not eat for thirty minutes after taking the tablet
If someone is unable to tolerate bisphosphonates, what alternative medication can be given?
Denosumab
Where are the common location of fragility fractures?
Vertebrae, hips, wrists
What is the recommended therapeutic plasma concentration of digoxin?
1-2 micrograms/l
What are some common symptoms of digoxin toxicity?
Nausea, vomiting, diarrhoea, visual disturbances, hallucinations and drowsiness
Can APTT be used to measure effects of warfarin as well as INR?
No APTT is a measurement of the anticoagulant effect of unfractionated heparin
What is the recommended INR range for a patient receiving warfarin for the prevention of a stroke?
2-3
What investigations are likely to be done when someone presents with confusion?
FBC- anaemia? infection?
U+Es
Calcium
LFTs
TFTs
Blood glucose
Drug levels
Urinalysis
CXR/sputum cultures
What are some non-pharmacological ways we can support people with dementia with their memory?
Calendars, clocks, spoken reminders, labelling cupboards/rooms and life story books
What are some non-pharmacological ways we can support people with dementia who are wandering?
Door alarms, sensor mats, GPS tracking
What are some non-pharmacological ways we can support people with dementia with their ADLs?
Visual prompts, verbal cues and encouragement, carers/POC, adaptive cutlery
What are some environmental adaptations OTs can put in place to help dementia patients?
Alarmed dossett boxes, stair rails, bathing equipment
What are some of the causes of delirium to initially screen for? (Using pneumonic PINCH ME)
Pain
Infection
Constipation
Dehydration
Medication
Environment
If a patient is not able to verbalise their pain, what can be used to help assess their pain?
Abbey pain scale
What are some delirium screening tests?
SQiD, CAM, 4AT
What is the non-pharmacological management of stress incontinence?
Pelvic floor exercises
What is the non-pharmacological management of urge incontinence?
Decaffeinated drinks, bladder training
What are some ways to reduce the distress of a patient with delirium?
Get them to speak to relative, assess and manage their pain, distracting techniques
What are Non-pharmacological ways that patients can help manage postural hypotension?
Withdraw any offending medication
Rise slowly from laying to sitting to standing
Avoid straining, coughing and prolonged standing in hot weather
Cross legs while standing
Raise head of bed
Small meals and coffee in the morning
Exercise
Increase salt and water intake
What is the definition of positive postural blood pressure test?
A drop in systolic BP by 20mmHg or
A drop below 90mmHg systolic on standing or
A drop in diastolic BP of 10mmHg with symptoms
What medications are commonly used for postural hypotension?
Fludrocortisone, midodrine
What is cognitive impairment?
A disturbance of higher cortical functions like memory, language, attention, thinking and judgement
What is the ICD 10 definition of dementia?
- cognitive impairment which is enough to impair ADLs
- problems with processing information, maintaining and directing attention
- clear consciousness
- symptoms for over 6 months
What does BPSD stand for?
Behavioural and psychological symptoms of dementia
Why do patients often need an ECG before starting a cholinesterase inhibitor?
They can cause bradycardia
What are common side effects of cholinesterase inhibitors used for dementia?
Headache, GI upset (nausea, vomiting, diarrhoea), agitation
What are side effects of NMDA antagonists used in dementia?
Headache, drowsiness, sedation, imbalances/falls
What are the four main clusters of BPSD?
Affective, apathetic, hyperactive, psychotic
What are features of hyperactive symptoms in dementia?
Hyperactive- aggression, disinhibition, resisting care, lability, night time disturbance
What are features of psychotic symptoms in dementia?
Hallucinations and delusions
What are features of affective symptoms in dementia?
Depression, hoarding, crying, wandering, anxiety
What are features of apathetic symptoms in dementia?
Reduced motivation and appetite, indifference
What are some features of early stage dementia?
Forgetfulness/memory problems are predominant cognitive abnormality
Subtle change in mood and behaviour
Minimal effect on day to day activities
What are some features of mid-stage dementia?
Memory problem more prominent and other cognitive difficulties emerge
More marked changes in behaviour
Difficulty with complex tasks but still managing ADLs
Awareness of disability begins to diverge from reality
What are some features of late stage dementia?
Severe and pervasive memory problems with other major cognitive disabilities
Marked changes in behaviour
Severe disability, inability to complete basic aspects of personal care requiring constant supervision
What is seen on structural brain imaging with Alzheimer’s disease?
Volume loss in the medial temporal lobe, posterior cingulate and precincts, loss of pes hippocampi
What is seen on structural brain imaging with vascular dementia?
May be evidence of infarcts, bleeds, white matter ischaemia
What is seen on structural brain imaging with FTD?
Frontotemporal atrophy
What is seen on structural brain imaging with alcoholic dementia?
Age-disproportionate cortical and WM atrophy
What are risk factors for delirium?
Fracture on admission, cognitive impairment, age, severity of illness admitted for, vision impairment, infection
Which common dugs can lead to drug-induced delirium?
Psychotropic drugs (antidepressants/psychotics, benzos), anti parkinsonian, anti cholinergic, opiates, diuretics
How is CAM (confusion assessment method) used to assess likelihood of delirium?
Diagnosis of delirium by CAM requires an acute onset and fluctuation course, inattention and either disorganised thinking or altered level of consciousness
What is the immediate action for patients with delirium?
Focused history and exam + collateral history
Identify and treat underlying causes
Does patient meet SIRS criteria and need sepsis 6 screen?
Cognitive assessment
Medication review
Put in high visibility bed
What are some non-neurodegenerative causes of dementia?
Infection: HIV, syphillis
Prion disease: CJD
Inflammatory: vasculopathies, sarcoidosis, autoimmune
Metabolic: poorly controlled endocrine disease, vitamin deficiencies
Genetic: APP, CADASIL, C9ORF72
Is faecal incontinence ever normal with ageing?
No it’s always abnormal and almost always curable
What is the most cause of faecal incontinence?
Faecal impaction with overflow accounts for 50%
If a patient with faecal incontinence is found to have reduced anal sphincter tone and reduced sensation, where might the pathology be?
Spinal cord pathology
Why might elederly patients be more at risk of faecal incontinence?
With age, rectum becomes more vacuous and anal sphincter can gape from haemorrhoids or chronic constipation
More likely to become constipated as they cannot exert the same amount of intrabdominal pressure
Can only hard stool cause faecal impaction?
Soft stool can fill the rectum and lead to faecal impaction
Can a patient be faecal loaded even if not stool is felt on DRE?
The impaction can be higher than the rectum
How can constipation be fatal?
There is a risk with chronic constipation that it can lead to stercoral perforation and ischaemic bowel
If stool is hard will stimulant be the appropriate management for their constipation?
No stool will require softening
What is some advice which can be trialled by patients with postural hypotension before starting medication?
Drinking plenty of fluids, when standing from sitting dorsiflex the feet first then rise slowly and cross their legs once up, compression stockings
What s meant when it is said capacity is time and decision specific?
Time- a patient may have capacity at one time of the day and not another or may not have capacity during an acute illness but have it once it resolves
Decision- they may have capacity to decide if they want personal care/blood tests but dont have consent for more complex decisions like about where to live
What are the five principles of the mental capacity act?
Presumption of capacity
All practical steps taken to allow autonomy
Allow unwise decisions
Least restrictive option
Best interest
What is the two staging capacity test?
Stage 1- is there impairment of the mind
Stage 2- a) understanding info (b) retaining info (c) weighing up info (d) communicating their decision
What is lasting power of attorney?
What is a lasting power of attorney?
A form which gives someone the power to make decisions for another person who lacks mental capacity. They would have had to complete this form while they have capacity
What is a deputy appointed by the court of protection?
This is someone appointed by the court of protection to make decisions about someone else who lacks capacity. This is similar to power of attorney but can be challenged by court of protection
What is a public guardian?
They are able to take action when there are concerns around an attorney or deputy
What is an advanced decision to refuse treatment?
Advance decisions are decisions a patient makes about not wanting a certain treatment later when they no longer have capacity. If they want to refuse life-sustaining/saving treatment then this will need to be signed by patient and a witness
What is an IMCA?
An independent mental capacity advocate is someone appointed to act on someone’s behalf to help make decisions for them
What is a deprivation of liberties safeguards?
This needs to be completed when a patient in a hospital or care home if needing to be deprived of their liberties or if they lack capacity to consent to their care and treatment in order to keep them safe from harm
What is DNACPR?
A decision to not attempt CPR which is made by the patient and/or their doctor/healthcare team
What are some precipitating factors of delirium?
New illness (e.g infection, urinary retention, constipation), falls, pain, poor oral intake, medication, sensory impairment
What investigations may be necessary following history and examination of a patient with suspected delirium?
Urinalysis, sputum culture, FBC, folate and B12, U+Es, HbA1c, calcium, LFTs, ESR/CRP, drug levels, TFTs, CXR, ECG
How can we manage delirium?
Correct any precipitating factors, optimise treatment for co-morbidities, de-escalation techniques, re-orientation strategies (reminding patient when and where they are, visible clocks), normalise their sleep wake cycle (stop napping, encourage bright light exposure in the day)
What are some risks of giving medication to reduce agitated behaviour with delirium?
Haloperidol increases risk of ischaemic stroke and confusion, also if they have PD it will worsen their motor symptoms
Lorazepam is sedating so can increase their risk of falls
What are some preventable causes of dementia?
Normal pressure hydrocephalus, malnutrition, alcoholism, depression, medications
What are pharmacological treatments for Alzheimer’s dementia?
Acetylcholinesterase inhibitors: Donepezil, rivastigmine, galantamine
NMDA receptor antagonist: memantine
What are signs of right sided heart failure?
Raised JVP, hepatomegaly and ankle oedema
How long after hip fracture surgery is a patient allowed to weight bear?
Immediately post-operatively
How long can it take for BPH treatment with finasteride before results are seen?
6 months
When is internal fixation used for a hip fracture?
Intracapsular NOF fracture with good pre-morbid status
What will blood tests show in osteoporosis?
Normal ALP
Normal Calcium
Normal Phosphate
Normal PTH
What classification system is used to classify neck of femur fractures?
The garden classification system
