Geriatrics

Question 1

What are the key criteria for delirium?

Answer 1

1) acute onset with waxing and waning, 2) inattention; AND one of 3) disorganized thinking vs 4) altered level of consciousness

Question 2

In what kind of dementia can there be dementia followed by parkinsonism symptoms?

Answer 2

Lewy Body Dementia

Question 3

What is the most common kind of dementia after AD?

Answer 3

Likely vascular dementia, or mix of vascular-AD

Question 4

Lab work up for reversible causes of dementia?

Answer 4

cbc, b12, tsh; optional: expanded opioid panel, serum tox, rpr

Question 5

What is the thinking on imaging in dementia diagnosis?

Answer 5

CT or MRI are reasonable, but diagnosis primarily clinical

Question 6

What are the three anti-Ach treatments?

Answer 6

donezpil (aricept), rivastigmine, galantamine

Question 7

What are the main side effects of these anti-Ach treatments?

Answer 7

GI side effects

Question 8

What is the criteria for Major Neurocognitive Disorder?

Answer 8

Reduction from baseline in one of the following domains: Learning and memory; Language; Executive function; Complex attention; Perceptual-motor function; Social cognition.

Interferes with activities of daily living

Doesn’t have a different diagnosis

Question 9

What are two anti-psychotics with less EPS?

Answer 9

clozapine and quetapine

Question 10

What are criteria for PD diagnosis?

Answer 10

bradykinesia plus RESTING tremor or rigidity; supportive criteria includes response to dopamine receptor agonist treatment

Question 11

What does sinemet (carbidopa-levodopa) do?

Answer 11

Does not prevent progression, but can improve movement - and thereby help with ADLs

Question 12

What are clinical signs of polymyalgia rheumatica? What three areas does it typically involve?

Answer 12

1) Bilateral aching/morning stiffness > 30 minutes, for atleast 1 month
2) and involving at least 2 of the following 3 areas - neck or torso; shoulders or proximal regions of the arms, hips or proximal aspects of thighs

Question 13

What is an associated condition with PMR?

Answer 13

temporal arteritis

Question 14

What should you check in patients with report of restless leg syndrome?

Answer 14

ferritin! Can treat Fe deficiency and see improvement. No sleep study is needed. it’s a clinical dx.

Question 15

What are some risk factors for osteoporosis?

Answer 15

age, W > M, glucocorticoid steroids, post-menopausal women, prior fragility fractures, family hx of fragitlity fractures, smoking, RA or type 1 diabetes, celiac disease/Crohn’s disease, PPIs/SSRIs

Question 16

What are our treatments for osteoporosis?

Answer 16

bisphosphonates, denosumab, raloxifene

Question 17

What is a serious adverse outcome and what are side effects of bisphophonates?

Answer 17

jaw necrosis; GI upset in about 7% (esophagitis < 1%)

Question 18

What is the deal with calcium supplementation?

Answer 18

Mild benefits if at all; risks of renal calculi and cardiac problems —– some benefit in nursing home frail population.

Question 19

What would you encourage for Ca in diet on a daily basis?

Answer 19

Encourage atleast 1 serving of dairy or equivalent serving per day – half cup of yogurt, cup of milk per day.

Question 20

Who gets screened and when for osteoporosis?

Answer 20

Women> 65. Not men (according to USPTSF)
Women > 50 with 2+ risk factors: fragility fracture (fracture without trauma, standing height at walking speed), glucocorticoids, history of parental hip fracture, smoking, heavy alcohol use, very low body weight, DM1, rheumatoid arthritis

Question 21

What is a FRAX score?

Answer 21

fracture risk assessment tool

Question 22

What is a measurement that is highly predictive of future vertebral fracture risk?

Answer 22

If there’s a >6cm height loss (between what you measure and what the patient says) or if >2cm prospective loss, it is highly predictive of someone who has had a vertebral compression fracture

Question 23

How do bisphosphonates work?

Answer 23

they inhibit osteoclasts – controlled apoptosis of these cells

Question 24

How do you counsel patients to take bisphosphonates?

Answer 24

Give on empty stomach with full glass of water - don’t eat for 30 minutes

Question 25

What is a harmful fracture risk from bisphosphonates and other osteoporosis treatments?

Answer 25

atypical femoral neck fractures (not limited to bisphosphonates). - refer to orthopedics

Question 26

What is the duration of treatment (depending on risk) of bisphosonates?

Answer 26

IF high risk, keep them on it; If patient is at moderate risk, has been on the bisphosphonate for at least 5 years, or IV bisphosphonate for at least 3 years, hasn’t had any new fractures and bone density is stable but still not > -2.5, consider holding the bisphosphonate; if low risk, can stop it after 3 years and repeat Dexa after 3 years.

Question 27

What are some secondary causes of osteoporosis?

Answer 27

endocrine disorders, malabsoprtion/GI issues, nutritional disorders

Question 28

What labs might you check for 2ndary causes of osteoporosis?

Answer 28

serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone levels

Question 29

How does memantine work? and who is it used in?

Answer 29

NMDA antagonist; used in moderate-to-severe dementia

Question 30

Is memantine mono therapy or can it be used in combination with donezepil?

Answer 30

Can be mono therapy, but also used in combo with donezpeil, can stabilize decline for about 1 year

Question 31

Which tachyarrythemia is most associated with syncope

Answer 31

AVNRT

Question 32

When to consider implantable loop recorder for syncope?

Answer 32

if syncope is recurrent, rare, and work up including event monitor has not been diagnostic; simple brief surgical procedure; long term monitoring, patient non-compliance eliminated; gold standard in recurrent unexplained syncope

Question 33

Neuroimaging in syncope

Answer 33

Not very valuable! EM study of over 1000 patients saw no clinically significant findings with neuro imaging

UNLESS focal neuro symptoms

Question 34

Key ddx for syncope

Answer 34

1) Cardiogenic - structural (valvular) OR obstructive (PE/effusion)
2) Hypovolemic/orthostatic
3) Vasovagal
4) Reduced sympathetic tone - meds?

Question 35

Main syncope work-up

Answer 35

EKG, telemetry, orthostatics, d-dimer/troponin PRN, TTE prn

Question 36

What is a first line tx for refractory orthostatic hypotension

Answer 36

fludrocortisone or midodrine (need TID tx for midodrine)
lower compression stockings / abd binders