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Finals Revision > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What can be used to manage hyperactive delirium?

A

Treat underlying cause
Modification of environment
Haloperidol 0.5mg if not PD patient
Lorazepam in PD patients

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2
Q

What are the pathological changes seen in Alzheimer’s?

A

Widespread cerebral atrophy: especially medial temporal lobe (hippocampus), widened sulci

Cortical plaques due to deposition of type A-Beta-Amyloid protein

Neurofibrillary tangles caused by abnormal tau protein

Deficit of ACh in neural pathways

Neurone apoptosis

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3
Q

What is the general pattern of Alzheimer’s Dementia?

A 
Gradual progression over 8-10 years
Episodic memory first affected (short term)
Anhedonia
Language impairment
Temporal and spatial disorientation
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4
Q

What are the 4 key features of Alzheimer’s?

A

4 As:

Agnosia, Aphasia, Apraxia, Amnesia

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5
Q

How is Alzheimer’s diagnosed?

A

Cognitive assessment: ACE III, MoCA, MMSE
CT scan: cerebral atrophy, widened sulci, narrowed gyri
MRI: medial temporal lobe atrophy

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6
Q

What treatment is available for Alzheimers?

A

First line: AChE inhibitors e.g. donepezil, rivastigmine, galantamine

+ NMDA antagonist: memantine

Non-pharm: wellbeing activities, cognitive stimulation therapy, group reminiscence therapy, CBT, treating any concurrent depression

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7
Q

What are the features of vascular dementia?

A

Stepwise deterioration in memory with ischaemic events
CV risk factors + history of CVD usually
Symptoms depend on area affected

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8
Q

How is vascular dementia diagnosed?

A

Hx CVD risk factors
CT scan: microangiopathy in the white matter, subcortical lacunar infarcts
MRI: global atrophy, lacunae, infarcts, diffuse white matter lesions

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9
Q

What are the features of frontotemporal dementia?

A

Earlier age of onset, steady deterioration
Intelligence, memory and orientation tend to be spared
Behaviour and language impairment

  • Behavioural (Picks): personality change, disinhibition
  • Non-fluent aphasia: language, speech + grammar impaired
  • Lopogenic: impaired phonology and repetition
  • Semantic: language + agnosia
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10
Q

How is frontotemporal dementia diagnosed?

A

MRI: Frontotemporal atrophy, asymmetric degeneration which later affects both hemispheres

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11
Q

What is the pathological change in lewy body dementia?

A

Intracellular deposition of a-synuclein

Pathological dopaminergic transmission

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12
Q

What is the difference between Lewy body dementia and Parkinson’s dementia?

A

LBD: memory deficit + psychotic symptoms start >1 year before motor symptoms

PD = vice versa

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13
Q

What are the features of Lewy body dementia?

A

Fluctuation in symptom severity

Visual hallucinations
Visuospatial and executive dysfunction (falls)
REM sleep disorder
Attention deficit
Development of parkinsonian symptoms
Urinary incontinence in some
Very sensitive to psychotropic medication - high risk of neuroleptic malignant syndrome

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14
Q

How is Lewy body dementia diagnosed?

A

DAT scan to demonstrate abnormal dopamine transmission

MRI usually unremarkable

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15
Q

How is Lewy body dementia diagnosed?

A

Rivastigmine

Most antipsychotics contraindicated so if necessary can use low dose quetiapine

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16
Q

What are differentials for dementia?

A 
Mild cognitive impairment
Delirium
Pseudodementia
Normal pressure hydrocephalus
Wernicke-Korsakoff's syndrome
Neurosyphilis / HIV
Creutzfeldt-Jakob disease
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17
Q

What is mild cognitive impairment?

A

Gradual onset, present most of the time for at least 2 weeks
Still able to independently perform ADLs & loss of <2 cognitive functions
Risk of developing dementia
ACE III score 80-88%

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18
Q

What is pseudodementia?

A

Memory loss associated with major depressive disorders in the elderly
Cognitive deficit onset after mood symptoms
Memory loss, low mood, anhedonia, flat affect, short answers
Responds well to antidepressant therapy

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19
Q

What triad of symptoms characterise normal pressure hydrocephalus?

A

Dementia + ataxia + urinary incontinence

Wet + wacky + wobbly

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20
Q

How is normal pressure hydrocephalus diagnosed?

A

Imaging: hydrocephalus with ventriculomegaly
LP: normal opening pressure but may alleviate symptoms

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21
Q

How is normal pressure hydrocephalus managed?

A

ventriculoperitoneal shunting

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22
Q

What is Creudzfeldt Jakob Disease?

A

rapidly progressive neurological condition caused by prion proteins

Prodrome: sleep disorder, headaches and fatigue

Rapidly progressing dementia, myoclonus, hallucinations, depression, ataxia, seizures

Mean onset 60 + patients normally die within a year

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23
Q

What are the main causes of falls?

A

DAMES

Drugs
Ageing
Medical conditions
Environment
Social factors
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24
Q

What should be included in confusion bloods?

A 
FBC
U&E
LFT
CRP
Glucose
Bone profile
TFT
Coagulation studies
Vitamin B12 + folate

Blood cultures
HIV/syphilis

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25
Q

What examination should you do in a fall presentation?

A 
A-E and full set of obs
CV and resp exam
Neuro and MSK assessment
Gait assessment
Cognitive assessment 
Vestibular + visual assessment
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26
Q

How can bone health be assessed?

A

Fracture risk should be calculated in anybody: >50 with hx of falls, >65 female, >75 male

DEXA scan and FRAX score
Check vitamin D and calcium levels

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27
Q

How can bone health be improved?

A

Conservative:
Increase activity, stop smoking, lose weight, nutrition, reduce alcohol
Medication review

Medical:
Calcium and vitamin D supplementation (adcal)
HRT in women
bisphosphonates first line

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28
Q

How can frailty be assessed?

A
  • Clinical Frailty Scale: 1-9
  • Frailty Index: ratio of actual health deficits: potential ones
  • Barthel Index of ADLs
29
Q

What tools can be used to assess confusion?

A

AMTS10 : abbreviated mental test score

CAM: confusion assessment method

4AT test: Alertness, AMT4, Attention, Acute + fluctuating course

30
Q

What is a good way to differentiate between dementia and delirium?

A

Testing for inattention-
Dementia patients can generally count from 20-1 with no difficulty whereas delirium patients tend to demonstrate poorer attention

31
Q

What are the criteria for treating UTI in the elderly?

A

Clinical sign and symptoms of UTI- not just urine dip
If presence of dysuria and 2+ symptoms, consider abx
Try to get an MSU before initiating treatment

32
Q

How should you manage clinical signs of UTI in a catheterised patient?

A

Remove catheter
MSU
New catheter
Start abx

33
Q

What are the most common causes of delirium?

A

PINCH ME

Pain
Illness
Nutrition
Constipation
Hydration (de)

Medication
Environment change

34
Q

How does Parkinson’s disease usually present?

A

Constipation, anosmia, loss of arm swing
Sleep disturbance and mood disturbance
Unilateral motor symptoms: resting pin-rolling tremor, shuffling gait, bradykinesia, rigidity

Stooped posture
Micrographia
Postural instability + orthostatic hypotension
Hypomimia
Hypophonia
35
Q

How is a diagnosis of Parkinson’s made?

A
  1. Bradykinesia + rigidity/tremor/postural instability
  2. Exclude other causes
  3. Supportive: (3+) unilateral onset, resting tremor, progressive symptoms, persisting asymmetry, response to levodopa, levo-induced chorea, gradual clinical cause
36
Q

What is the best antiemetic to use in PD?

A

Domperidone
Cyclizine and ondansetron also safe to use

Metoclopramide and chlorperazine contraindicated

37
Q

How is PD managed?

A
  1. Conservative: physiotherapy, SALT, movicol/enema, OT, cognitive engagement, support groups
  2. Medical management - reserve for when symptoms become problematic

a) Co-careldopa: levodopa + carbidopa to prevent peripheral metabolism
Increases in dose size may be needed over time but ^ risk side effects

b) dopamine agonists e.g. ropinirole / pramipexole
c) MAO-B inhibitors e.g. seligiline, rasagiline
d) COMT inhibitors e.g. entacapone

Anticholinergics can help with tremor but worsen cognitive symptoms

38
Q

What are differentials for PD?

A 
Vascular parkinsonism
Lewy body dementia
Drug-induced PD
Multi-systems atrophy
Progressive supranuclear palsy
Normal pressure hydrocephalus
Corticobasal degeneration
39
Q

What are features of vascular Parkinsonism?

A

Predominantly lower body symptoms- leg rigidity
Loss of expression
Tremor less common

50% respond to levodopa

40
Q

What medications commonly cause drug-induced Parkinsonism?

A

Anti-psychotics
Metoclopramide
Prochlorperazine

Differs from PD as typically symmetrical symptoms

41
Q

What is multi-systems atrophy?

A

Autonomic instability - postural / essential hypotension
Bladder instability
Symmetrical Parkinsonism

42
Q

What is progressive supranuclear palsy?

A

Early falls, truncal rigidity and vertical gaze palsy

Hummingbird sign on MRI - reduced midbrain volume

43
Q

What are differentials for tremor?

A 
Essential tremor
Parkinsonism
Drug-induced tremor
Hypoglycaemia
Anxiety
Intention tremor 
Alcohol withdrawal
Hyperthyroidism
CO2 retention
Encephalopathy/encephalitis
44
Q

What are the causes of intention tremor?

A

MS
Cerebellar pathology
Midbrain stroke
Wilson’s disease

45
Q

What are the features of refeeding syndrome?

A 
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
Water retention
Anaemia 
Low serum thiamine
Hyperglycaemia

Arrhythmias, bradycardia, hypotension, SOB, respiratory muscle weakness, neurological symptoms

46
Q

Which preceding medical legislation is legally binding with regards to refusing treatments?

A

Advanced decision to refuse treatment

Advanced statement = non-legally binding, used to help make BI decisions

47
Q

What are the grades of pressure sore?

A

1: erythema, non-blanching
2: partial-thickness skin loss involving epidermis and dermis, superficial ulcer
3: Full thickness skin loss with damage/necrosis to subcutaneous tissue
4: Extensive destruction, tissue necrosis and damage to muscle/bone/supporting structures

48
Q

What are the features of a left anterior cerebral artery stroke?

A

Right sided hemiplegia
Cognitive dysfunction / behavioural change
Speech disturbance

49
Q

What are the symptoms of right cerebral artery stroke?

A

Left sided hemiplegia

Executive dysfunction and disinhibition

50
Q

What are the symptoms of left middle artery stroke?

A

Right sided hemiplegia: face, arm, leg
Right homonymous hemianopia
Speech and language disturbance- dysphasia, dysarthria

51
Q

What are the symptoms of right middle artery stroke?

A

Left hemiplegia: face, arm, leg, similar sensory loss
Left-sided neglect
Left homonymous hemianopia

52
Q

What are the symptoms of posterior cerebral artery stroke?

A

Contralateral homonymous hemianopia or cortical blindness
Memory deficit
Contralateral sensory loss
Decreased consciousness if thalamus affected

May have pure sensory loss

53
Q

What are the symptoms of brainstem stroke?

A

Ipsilateral facial nerve numbness and weakness
Contralateral limb numbness and weakness
Nystagmus, vertigo, ataxia
Diplopia, ophthalmoplegia, dysarthria, tongue deviation
Locked in syndrome

54
Q

What are the symptoms of cerebellar stroke?

A 
Ataxia
Vertigo, nausea, nystagmus
Dysarthria
Decreased consciousness
Increased risk of oedema, herniation and transtentorial coning
55
Q

How would you manage somebody presenting with suspected TIA?

A

FAST tool
EXCLUDE HYPOGLYCAEMIA
Loading dose aspirin 300mg for 14 days
Referral to TIA clinic within 24 hours

56
Q

What is secondary prevention following a TIA?

A 
Lifestyle change
75mg clopidogrel daily
Atorvastatin
ACE-I / CCB / Thiazide for BP control 
If AF, anticoagulate if indicated by SPARC / CHADSVASC
57
Q

What are features of carotid artery stenosis?

A

Often asymptomatic
Stroke / TIA / amaurosis fugax / CRAO
Carotid bruit may be heart
Sudden dizziness/loss of balance

58
Q

How is carotid artery stenosis managed?

A

Lifestyle change

Medical management: statin, antiplatelet, BP and DM control

Surgical management: carotid endarterectomy - done within 2 weeks if significant

Indications for surgery: symptomatic + >70% stenosis / >50% with other comorbidity
asymptomatic + >80% stenosis / >60% with other comorbidity

59
Q

What scoring system should be used on presentation of stroke and after treatment?

A

NIHSS score

60
Q

How does ischaemic stroke differ from haemorrhagic?

A

haemorrhagic stroke symptom onset tends to be more gradual

Very sudden with ischaemic

61
Q

What imaging modality is best in stroke?

A

Non-contrast CT head ASAP
May be supplemented by CT angio to identify location of a clot

Ischaemic tissue goes hypodense initially and when chronic may become hyperdense with mineralisation

62
Q

How should somebody presenting with stroke be managed?

A
  1. FAST tool, A-E + obs
  2. Neuro exam
  3. Rule out hypoglycaemia
  4. Urgent non-contrast CT

If no signs of haemorrhage and stroke confirmed:
Thrombolysis <4 hrs / thrombectomy <24 if salvageable tissue
If not, 300mg aspirin 14 days -> secondary prevention

63
Q

How do you manage haemorrhagic stroke?

A

Reverse any anticoagulation and correct any clotting abnormality
Lower SBP to 130-140 (not lower to prevent cerebral ischaemia)
Consider decompressive craniotomy

64
Q

What are contraindications to thrombolysis?

A 
Stroke >4.5 hours ago
Current bleeding
Recent surgery/bleed
Current anticoagulation
Recent / previous stroke
65
Q

What are the Bamford criteria for total anterior circulation stroke?

A

Unilateral hemiplegia and sensory loss
Homonymous hemianopia
Higher cerebral dysfunction

66
Q

What are the Bamford criteria for a partial anterior circulation stroke?

A

2 of:
Unilateral hemiplegia and sensory loss
Homonymous hemianopia
Higher cerebral dysfunction

67
Q

What are the Bamford criteria for a lacunar syndrome?

A 
One of:
Pure sensory stroke
Pure motor stroke
Sensori-motor
Ataxic hemiparesis
68
Q

What are the features of posterior circulation syndrome?

A

1 of:
Cranial nerve palsy + contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Gaze palsy
Cerebellar dysfunction
Isolated homonymous hemianopia / cortical blindness

Finals Revision (23 decks)

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