Geriatrics Flashcards
What can be used to manage hyperactive delirium?
Treat underlying cause
Modification of environment
Haloperidol 0.5mg if not PD patient
Lorazepam in PD patients
What are the pathological changes seen in Alzheimer’s?
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
What is the general pattern of Alzheimer’s Dementia?
Gradual progression over 8-10 years Episodic memory first affected (short term) Anhedonia Language impairment Temporal and spatial disorientation
What are the 4 key features of Alzheimer’s?
4 As:
Agnosia, Aphasia, Apraxia, Amnesia
How is Alzheimer’s diagnosed?
Cognitive assessment: ACE III, MoCA, MMSE
CT scan: cerebral atrophy, widened sulci, narrowed gyri
MRI: medial temporal lobe atrophy
What treatment is available for Alzheimers?
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
What are the features of vascular dementia?
Stepwise deterioration in memory with ischaemic events
CV risk factors + history of CVD usually
Symptoms depend on area affected
How is vascular dementia diagnosed?
Hx CVD risk factors
CT scan: microangiopathy in the white matter, subcortical lacunar infarcts
MRI: global atrophy, lacunae, infarcts, diffuse white matter lesions
What are the features of frontotemporal dementia?
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
How is frontotemporal dementia diagnosed?
MRI: Frontotemporal atrophy, asymmetric degeneration which later affects both hemispheres
What is the pathological change in lewy body dementia?
Intracellular deposition of a-synuclein
Pathological dopaminergic transmission
What is the difference between Lewy body dementia and Parkinson’s dementia?
LBD: memory deficit + psychotic symptoms start >1 year before motor symptoms
PD = vice versa
What are the features of Lewy body dementia?
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
How is Lewy body dementia diagnosed?
DAT scan to demonstrate abnormal dopamine transmission
MRI usually unremarkable
How is Lewy body dementia diagnosed?
Rivastigmine
Most antipsychotics contraindicated so if necessary can use low dose quetiapine
What are differentials for dementia?
Mild cognitive impairment Delirium Pseudodementia Normal pressure hydrocephalus Wernicke-Korsakoff's syndrome Neurosyphilis / HIV Creutzfeldt-Jakob disease
What is mild cognitive impairment?
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%
What is pseudodementia?
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
What triad of symptoms characterise normal pressure hydrocephalus?
Dementia + ataxia + urinary incontinence
Wet + wacky + wobbly
How is normal pressure hydrocephalus diagnosed?
Imaging: hydrocephalus with ventriculomegaly
LP: normal opening pressure but may alleviate symptoms
How is normal pressure hydrocephalus managed?
ventriculoperitoneal shunting
What is Creudzfeldt Jakob Disease?
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
What are the main causes of falls?
DAMES
Drugs Ageing Medical conditions Environment Social factors
What should be included in confusion bloods?
FBC U&E LFT CRP Glucose Bone profile TFT Coagulation studies Vitamin B12 + folate
Blood cultures
HIV/syphilis
What examination should you do in a fall presentation?
A-E and full set of obs CV and resp exam Neuro and MSK assessment Gait assessment Cognitive assessment Vestibular + visual assessment
How can bone health be assessed?
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
How can bone health be improved?
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
How can frailty be assessed?
- Clinical Frailty Scale: 1-9
- Frailty Index: ratio of actual health deficits: potential ones
- Barthel Index of ADLs
What tools can be used to assess confusion?
AMTS10 : abbreviated mental test score
CAM: confusion assessment method
4AT test: Alertness, AMT4, Attention, Acute + fluctuating course
What is a good way to differentiate between dementia and delirium?
Testing for inattention-
Dementia patients can generally count from 20-1 with no difficulty whereas delirium patients tend to demonstrate poorer attention
What are the criteria for treating UTI in the elderly?
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
How should you manage clinical signs of UTI in a catheterised patient?
Remove catheter
MSU
New catheter
Start abx
What are the most common causes of delirium?
PINCH ME
Pain Illness Nutrition Constipation Hydration (de)
Medication
Environment change
How does Parkinson’s disease usually present?
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
How is a diagnosis of Parkinson’s made?
- Bradykinesia + rigidity/tremor/postural instability
- Exclude other causes
- Supportive: (3+) unilateral onset, resting tremor, progressive symptoms, persisting asymmetry, response to levodopa, levo-induced chorea, gradual clinical cause
What is the best antiemetic to use in PD?
Domperidone
Cyclizine and ondansetron also safe to use
Metoclopramide and chlorperazine contraindicated
How is PD managed?
- Conservative: physiotherapy, SALT, movicol/enema, OT, cognitive engagement, support groups
- 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
What are differentials for PD?
Vascular parkinsonism Lewy body dementia Drug-induced PD Multi-systems atrophy Progressive supranuclear palsy Normal pressure hydrocephalus Corticobasal degeneration
What are features of vascular Parkinsonism?
Predominantly lower body symptoms- leg rigidity
Loss of expression
Tremor less common
50% respond to levodopa
What medications commonly cause drug-induced Parkinsonism?
Anti-psychotics
Metoclopramide
Prochlorperazine
Differs from PD as typically symmetrical symptoms
What is multi-systems atrophy?
Autonomic instability - postural / essential hypotension
Bladder instability
Symmetrical Parkinsonism
What is progressive supranuclear palsy?
Early falls, truncal rigidity and vertical gaze palsy
Hummingbird sign on MRI - reduced midbrain volume
What are differentials for tremor?
Essential tremor Parkinsonism Drug-induced tremor Hypoglycaemia Anxiety Intention tremor Alcohol withdrawal Hyperthyroidism CO2 retention Encephalopathy/encephalitis
What are the causes of intention tremor?
MS
Cerebellar pathology
Midbrain stroke
Wilson’s disease
What are the features of refeeding syndrome?
Hypomagnesaemia Hypokalaemia Hypophosphataemia Water retention Anaemia Low serum thiamine Hyperglycaemia
Arrhythmias, bradycardia, hypotension, SOB, respiratory muscle weakness, neurological symptoms
Which preceding medical legislation is legally binding with regards to refusing treatments?
Advanced decision to refuse treatment
Advanced statement = non-legally binding, used to help make BI decisions
What are the grades of pressure sore?
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
What are the features of a left anterior cerebral artery stroke?
Right sided hemiplegia
Cognitive dysfunction / behavioural change
Speech disturbance
What are the symptoms of right cerebral artery stroke?
Left sided hemiplegia
Executive dysfunction and disinhibition
What are the symptoms of left middle artery stroke?
Right sided hemiplegia: face, arm, leg
Right homonymous hemianopia
Speech and language disturbance- dysphasia, dysarthria
What are the symptoms of right middle artery stroke?
Left hemiplegia: face, arm, leg, similar sensory loss
Left-sided neglect
Left homonymous hemianopia
What are the symptoms of posterior cerebral artery stroke?
Contralateral homonymous hemianopia or cortical blindness
Memory deficit
Contralateral sensory loss
Decreased consciousness if thalamus affected
May have pure sensory loss
What are the symptoms of brainstem stroke?
Ipsilateral facial nerve numbness and weakness
Contralateral limb numbness and weakness
Nystagmus, vertigo, ataxia
Diplopia, ophthalmoplegia, dysarthria, tongue deviation
Locked in syndrome
What are the symptoms of cerebellar stroke?
Ataxia Vertigo, nausea, nystagmus Dysarthria Decreased consciousness Increased risk of oedema, herniation and transtentorial coning
How would you manage somebody presenting with suspected TIA?
FAST tool
EXCLUDE HYPOGLYCAEMIA
Loading dose aspirin 300mg for 14 days
Referral to TIA clinic within 24 hours
What is secondary prevention following a TIA?
Lifestyle change 75mg clopidogrel daily Atorvastatin ACE-I / CCB / Thiazide for BP control If AF, anticoagulate if indicated by SPARC / CHADSVASC
What are features of carotid artery stenosis?
Often asymptomatic
Stroke / TIA / amaurosis fugax / CRAO
Carotid bruit may be heart
Sudden dizziness/loss of balance
How is carotid artery stenosis managed?
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
What scoring system should be used on presentation of stroke and after treatment?
NIHSS score
How does ischaemic stroke differ from haemorrhagic?
haemorrhagic stroke symptom onset tends to be more gradual
Very sudden with ischaemic
What imaging modality is best in stroke?
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
How should somebody presenting with stroke be managed?
- FAST tool, A-E + obs
- Neuro exam
- Rule out hypoglycaemia
- 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
How do you manage haemorrhagic stroke?
Reverse any anticoagulation and correct any clotting abnormality
Lower SBP to 130-140 (not lower to prevent cerebral ischaemia)
Consider decompressive craniotomy
What are contraindications to thrombolysis?
Stroke >4.5 hours ago Current bleeding Recent surgery/bleed Current anticoagulation Recent / previous stroke
What are the Bamford criteria for total anterior circulation stroke?
Unilateral hemiplegia and sensory loss
Homonymous hemianopia
Higher cerebral dysfunction
What are the Bamford criteria for a partial anterior circulation stroke?
2 of:
Unilateral hemiplegia and sensory loss
Homonymous hemianopia
Higher cerebral dysfunction
What are the Bamford criteria for a lacunar syndrome?
One of: Pure sensory stroke Pure motor stroke Sensori-motor Ataxic hemiparesis
What are the features of posterior circulation syndrome?
1 of:
Cranial nerve palsy + contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Gaze palsy
Cerebellar dysfunction
Isolated homonymous hemianopia / cortical blindness
