Geriatric Medicine Flashcards
What age groups does geriatric medicine tackle
Over 75s
What changes to pharmacokinetics (how body deals with drug) can happen with age
- Reduced volume of drug distribution
- Reduced liver metabolism
- Reduced renal blood flow and mass reduced clearance of water soluble drugs
What changes to the pharmacodynamics (what drug does to the body) can occur with age
Increased sensitivity of body to drugs
Lower doses often needed
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In geriatrics never stop at a single diagnosis and always consider several co-existing conditions
What common things often complicate drugs administration and diagnoses in geriatric patients
Polypharmacy
Pre-existing disease
What is the atypical presentation of geriatric problems
- Frequently present general deterioration, functional decline
- Acute disease may be hidden but precipitates impairment in other systems
- Falls, confusion, reduced mobility are likely to be medical problems in disguise
- Different illnesses can present as one of ‘geriatric giants’
What are considered the ‘geriatric giants’ - symptoms of geriatric disease
- Incontinence
- Immobility
- Instability
- Intellectual impairment
- Iatrogenic disease
- Infection
What is osteoporosis
Skeletal disease with low bone mass and micro deterioration of bone tissue - more fragile and susceptible to fracture
Slow and progressive and symptomatic reduction in skeletal tissue until fracture occurs
What are the common fracture sites in osteoporosis and what symptoms arise with it
Common sites - spine, wrist, hip
Symptoms - pain, disability, loss of independence, premature death
Describe the aetiologies of osteoporosis
- Mainly affects post-menopausal women as a result of oestrogen deficiency
- In men 50% of cases associated with hypogonadism, corticosteroid treatment, alcohol excess
What are some non-modifiable risk factors of osteoporosis
- Female
- Family history of osteoporosis
- Caucasian or asian ethnicity
- Age > 65 years
- Previous fragility fracture
What are some modifiable risk factors of osteoporosis
- Low BMI
- Smoking
- Alcohol excess
- Low calcium intake and vitamin D deficiency
- Inactivity
What are some hormonal risk factors of osteoporosis
- Menopause before age 45 years
- Male hypogonadism
What are some drug-related risk factors of osteoporosis
- Glucocorticoids
- Anticonvulsants
- Cytotoxic therapy
What are some secondary causes of osteoporosis
- Rheumatoid arthritis
- Hyperthyroidism
- Malabsorption
- Chronic liver disease
- Primary hyperparathyroidism
- Prolonged immobilisation
- Anorexia nervosa
What diagnosis methods are there for osteoporosis
- Marked osteopenia on plain x-ray
- Previous fragility fracture
- Identification of risk factors for osteoporosis
- Standard for diagnosis is assessment of bone mineral density by axial dual energy X-ray absorptiometry (DEXA scan)
What is the action of vitamin D and bone health
- Regulates calcium and phosphate absorption and metabolism
How is most vitamin D produced
Through action of sunlight on skin to produce vitamin D3 - some from meat and vegetables
What symptoms are there for vitamin D deficiency
Asymptomatic, muscular aches and bone pains and osteomalacia
What lifestyle changes can be treatment for osteoporosis
- Smoking cessation, alcohol moderation
- Healthy balanced diet with good calcium intake
- Appropriate sun exposure
- Low salt intake
- Id oral corticosteroids required low dose and use of steroid sparing agents
- Regular weight-bring exercise
What pharmacological treatments are there for osteoporosis
- Calcium and vitamin D supplements
- Bisphosphonates e.g. alendronate, etidronate, risedronate
- Raloxifene
- Teriparatide
- Calcitonin
- Strontium ranelate
What are the effects of bisphosphonates on bone health
- Reduces rate of bone turnover
- Alendronate can cause oesophagitis and oral ulceration
- Concern over potential MRONJ
Why is HRT no longer used for long term osteoporosis treatment
Risk of breast cancer and cardiovascular disease
Describe the features/characteristics of B/MRONJ
- 90% of cases associated with cancer treatment IV BP
- Mandible more commonly involved
- Asymptomatic or painful
- Multifocal presentations reported
- Preceded by surgical intervention or extraction in 60%
- Exposed bone - secondary infection can lead to sinuses or fistulae
What are the indications for the use of bisphosphonates
- Prevention and treatment of osteoporosis in post-menopausal women
- Prophylaxis of corticosteroid-associated osteoporosis
- Treatment of hypercalcaemia of malignancy
- Management of bone metastases e.g. breast cancer
- Management of osteolytic lesion in multiple myeloma
- Management of Paget’s disease
What bisphosphonates could be used for osteoporosis
Alendronate
Ibandronate
What bisphosphonate would be used for pagets disease of bone
Risedronate
What bisphosphonate would be used for corticosteroid associated osteoporosis
Etidronate
What bisphosphonate would be used for hypercalcaemia of malignancy
Pamidronate
What bisphosphonate would be used for osteolytic lesions
Zoledronate
What are the clinical presentations of B/MRONJ
- Delayed healing following a dental extraction or other oral surgery
- Pain, soft tissue infection and swelling
- Numbness, paraesthesia
- Exposed bone
- Non-exposed variant
What are the management options of B/MRONJ
- Identify patients at risk and educate
- If surgical intervention necessary atraumatic technique
- Stop BSP treatment, nutritional supplements, hyperbaric oxygen, chlorhexidine, systemic antibiotics
What are the 2 main types of transient ischaemic attack and stroke
Cerebral infarction (80%) Intracerebral haemorrhage (15%) (incl. subarachnoid haemorrhage 5%)
Describe cerebral infarction
- Blockage of arterial blood supply by small vessel occlusion, artherothromboembolism e.g. from carotids or embolisation e.g. from atrial fibrillation, MI
- results in disturbance to neuronal electrical activity (reversible) and cellular membrane integrity (irreversible)
Describe intracerebral haemorrhage
Rupture of blood vessels in brain tissue -> direct neuronal injury and cerebral oedema
What are some of the risk factors of cerebrovascular accidents
- Hypertension
- Smoking
- Diabetes mellitus
- Heart disease (Valvular ischaemic, atrial fibrillation)
- Peripheral vascular disease
- Past TIA/stroke
- Polycythaemia
- Carotid bruit
- OCP
- Hyperlipidaemia
- Alcoholism
How long do Transient Ischaemia Attacks last for (TIA)
Neurological signs and symptoms resolve within 24 hours - embolic
What are the clinical features of Stroke/TIA
- Involves sudden onset of a focal neurological deficit
- Occasionally with further progression over hours
- Ensuing disability relates to distribution of affected artery but collateral supplies may make this less clear
- Difficult to distinguish ischaemic and haemorrhagic stroke clinically
What are the clinical features of stroke/TIA in the anterior (carotid) circulation
- Cortical dysfunction: dysphasia, sensory or visual inattention, hemianopia
- Monoccular blindness
- Unilateral weakness
- Unilateral sensory disturbance
- Dysarthria
- Neuromuscular dysphagia
What are the clinical features of stroke/TIA in the posterior (vertebrobasilar) circulation
- Cranial nerve palsy
- Ataxia/incoordination/disequilibrium
- Diplopia
- Bilateral visual loss
- Unilateral/bilateral weakness or sensory disturbance
- Dysarthria
- Neuromuscular dysphagia
What are the acute management options for stroke/TIA
- Maintain patients airway - avoid hypoxia or aspiration
- Monitor blood glucose (between 4-11)
- Monitor BP - treatment of even very high BPs may be more harmful
- Urgent CT/MRI - if thrombolysis considered, high risk of haemorrhage, unusual presentation
- Nil by mouth
- antiplatelet agents - once haemorrhagic stroke excluded
What secondary prevention strats are there for stroke/TIA
- Antiplatelet agents - aspirin, clopidogrel, dipyridamole
- Anticoagulation - atrial fibrillation - warfarin
- Risk factor management - hypertension, lipids, smoking, dietary advice - salt restriction
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1/3 of stroke survivors will suffer a further stroke
What is the definition of dementia
- Acquired, global and progressive impairment of mental function
Describe the presentation of dementia
- Initial presentation is of memory loss over months or years
- in later stages non-cognitive symptoms like agitation, aggression or apathy become apparent
- May also be wandering, hallucinations, slow repetitive speech, mood disturbance
Name some types of dementia
- Alzeheimer’s disease
- Vascular dementia
- Dementia with Lewy Bodies
- Fronto-temporal dementia syndrome
- Other
What are some rare causes of dementia
- Hypothyroidism
- Reduced vitamin B12/ folate/ thiamine (alcoholism)
- Depression
- Syphilis
- Tumours
- Parkinsons
- HIV
- Pellagra
What is the most common form of vascular dementia
Multi-infarct dementia
Describe multi-infarct dementia
Typically step-wise with periods of sudden decline interspersed with periods of relative stability
What is the mean survival time from the onset of alzheimer’s disease
7 years
Describe the presentation of alzheimer’s disease
- Enduring, progressive and global cognitive impairment
- Impaired visuospatial skill, memory, verbal abilities, planning abilities and lack of insight
- Later - irritability, mood disturbance, behavioural change, psychosis, agnosia
- Finally become sedentary and take no interest
What is the cause of alzheimer’s disease
- Accumulation of Beta amyloid peptide (degradation product of amyloid precursor protein)
- Results in progressive neuronal damage, neurofibrillary tangles, amyloid plaques, loss of neurotransmitter acetylcholine
- May also be vascular effects
What management options are there for alzheimer’s disease
- Symptoms may be magnified by unfamiliar environments or people
- Develop routines
- Acetylcholinesterase inhibitors e.g. done-evil, rivastigmine
- Meticulous BP control
- Treat depression
- Avoid drugs which will exacerbate cognitive impairment
