Geriatrics Flashcards
Definition of delerium
Acute confusional state which fluctuates with severity, and is reversible. Usually caused by organic causes.
What’s hypoactive delirum?
lethargy, apathy, excessive sleeping, inattention, withdrawn, motor retardation, drowsy, unrousable
What is hyperactive delirum?
Agitation, aggression, restlessness, readily distracted, wandering, delusions, hallucinations
What is a stroke?
sudden onset focal neurological deficit of vascular aetiology with symptoms lasting over 24hrs (or with evidence of infarct on imaging)
Risk factors for stroke
age, male sex, family hx, hypertension, smoking, DM, AF
What is Wallenburg’s syndrome (lateral medullary syndrome)
ipsilateral loss of pain and temp sensation on face
contralateral loss of pain and temp on body
acute mx of stroke
DR ABCDE
distinguish between iachaemia and haemorrhagic (weighted MRI)
Alteplase (tissue plasminogen activator) indicated in pts presenting within 4.5 hrs onset (no CI to thrombysis: recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, INR)
if hyperacute tx not offered, pts should receive 300mg aspirin once daily for 2 weeks
Chronic mx of stroke
HALTSS
hypertension: anti-hypertensives (2 weeks post-stroke)
antiplatelet therapy: clopidegrel 75mg OD (pts ischaemic stroke 2ndary to AF: warfarin or rivaroxaban/apixaban)
lipid lowering therapy: high dose atorvastatin 20-80mg ON
Tobacco: smoking cessation
Sugar: screening for diabetes and managed appropiately
Surgery: pts with ipsilateral carotid artery stenosis more than 50% referred for carotid endarterectomy
An 80 year old man with a history of epilepsy presents to the ED following a laceration to his leg after a bike accident. He is given a painkiller to help his discomfort and waits for a hour before the senior house officer has a chance to stitch his wound. He is found by the nurse seizing. What medication was likely given?
Tramadol
type of opiate with some SNRI abilities
cause delerium, lower seizure threshold and impotence
What is pseudo-dementia?
AKA depressive dementia
important differential in elderly
can lead to psychocmotor slowing, memory impairment and difficulty concentrating.
pts often present with self neglect and sig weight loss as result
Clinical features of Lewy body dementia
fluctuating cognition, parkinsonism (increased no. of falls), visual hallucinations
How does normal pressure hydrocephalus present
dementia, urinary incontinence and gat disturbance
Trimethoprim, CI, what it’s used for, side effects
CI: 1st trimester pregnancy
1st line UTI normally (not in pregnancy)
inhibits dihydrofolate reductase and interfering with folate metabolism.
Can lead to transient rise in creatinine (like in the elderly) - reduces cretintine excretion by kidneys
Does not affect GFR
Mx of postural hypotension
depends on cause
ensure adequate hydration
Medication review
Reduce adverse outcomes (fall alarm, soft flooring)
Behavioural changes (rise from sitting slowly, adequate hydration, dorsiflex feet first)
Compression stockings
Pharmocotherapy: fludrocortisone, midodrine
What is viagra, when is it used, side effects and CI
sildenafil for erectile dysfunction
phosphodiesterase 5 (PDE5) inhibitor - enhances effect of nitric oxide causing smooth muscle relaxation and subsequent penile erection
CI : pts taking organic nitrates
Side effects: flushing, headache, dyspepsia, nasal congestion, dizziness, diarrhoea, rashes and UTIs
A 72 year old woman with Parkinson’s disease is managed with Ropinirole (a dopamine agonist). Which is the most important side effect to monitor for?
Impulsivity
pathological gambling, hypersexuality.
An 87 year old woman with a background of Parkinson’s disease, previous strokes and vascular dementia is admitted to the acute ward as her daughter is not coping at home with her. The patient has a history of aggressive outbursts, which her daughter verifies. Within a few hours of admission the patient appears distressed at her change of environment and becomes very agitated, shouting aggressively, pulling out her cannula and spitting and trying to hit staff. Nurses have tried several de-escalation techniques, but are unable to calm her.
What is the next most appropriate course of action?
PO/IM lorazepam
- haloperidol CI in parkinson’s
An 87 year old woman with a background of Parkinson’s disease, previous strokes and vascular dementia is admitted to the acute ward as her daughter is not coping at home with her. The patient has a history of aggressive outbursts, which her daughter verifies. Within a few hours of admission the patient appears distressed at her change of environment and becomes very agitated, shouting aggressively, pulling out her cannula and spitting and trying to hit staff. Nurses have tried several de-escalation techniques, but are unable to calm her.
What is the next most appropriate course of action?
PO/IM lorazepam
- haloperidol CI in parkinson’s
What abx reduce seizure threshold?
Ciprofloxacin and other quinolones
A 72-year-old man with end stage renal disease on haemodialysis was admitted following a fracture of his left radius. In the ED he was given some painkillers. You were asked by the nurse to check up on him three hours later as he is no longer as alert as before. His vitals are: BP 110/76, HR 80, Afebrile, RR 7, oxygen saturations 85% on room air. Which medication was most likely given in the ED to cause this picture?
Morphine
sx of opiate induced resp depression
opiates normally renally excreted, should be used cautiously in those with AKI, CKD or on haemodialysis
An 83 year old gentleman with a history of congestive heart failure (EF 40%), STEMI was seen in your clinic two months ago. You uptitrated his beta blockers, his ACE inhibitor, furosemide, atorvastatin and spironolactone at the same time. Generally he feels less short of breath with less swelling in his ankles compared to before. Since last visit however he notes he is always thirsty and can get a little dizzy when stands he too quickly. On clinical exam he has dry mucous membranes, reduced skin turgor, clear lungs and no peripheral oedema. His orthostatics are: lying BP 122/67, HR 65 to standing BP 100/54, HR 85. Which of these medications is most likely the cause of his symptoms?
Furosemide (loop diuretic)
can reduce BP significantly - lead to clinical signs dehydration and intravascular depletion
A 56-year-old woman with metastatic breast cancer is complaining of pain. She is on regular medication of oral morphine sulphate modified-release (MR) 15 mg twice daily, and her pain is usually well controlled and the morphine well tolerated. Other than the pain, she is feeling well and has no injuries.
What would be the most appropriate dose for breakthrough pain relief?
oral morphine immediate release 5mg as required up to 4 hourly
tolerating morphine well, no indication to change opiate
breakthrough pain relief calculated as a sixth of daily total dose.
Her daily dose is 30mg (15 + 15). one sixth of this is 5mg
mx for mild-moderate Alzheimer’s disease
donepezil - 1st line
type of acetylcholinesterase inhibitor,
Memantine is 2nd line
Clinicl presentation of postural hypotension
dizziness
syncope
falls fractures
occurs more frequently following meals or exercise and in warm environment
sometimes precipitated by cough or defecating
may occur several minutes after standing up
Dx for postural hypotension
fall of 20mmg or more in systolic BP or fall of 10mmHg or more in diastolic
Causes of postural hypotension
drugs: vasodilators, diuretics, negative inotropes, antidepressants, opiates
chronic hypertension
dehydration
sepsis
autonomic nervous dysfunction (Parkinson’s)
adrenal insufficiency
What medication can be used to raise BP
fludrocortisone
mainly used for mineralcorticoid properities, leading to sodium retention and effective blood volume and therefore pressure.
Risk factors for Alzheimer’s dementia
down syndrome
amyloid precursoe protein gene mutation
age
1st degree relative
sx of Alzheimer’s dementia
short term memory loss (progressive + persistent)
global cog impairment
irritable, mood swings, apathy
Inx for Alzheimer’s dementia
CT
MMSE
Pathophysiology of Lewy body dementia
cerebral atrophy + lewy bodies
alpha synuclein positive
cytoplasmic inclusions in neurons
RF for Lewy body dementia
> 60
male
family hx
Parkinson’s
Lewy body disease
Sx of Lewy body dementia
Visual hallucinations
REM sleep disturbance
cognitive fluctuation
Falls
Ix for Lewy body dementia
SPECT - shows reduced metabolism and reduced occipital perfusion
Mx for Lewy body dementia
levodopa, DA agonists
CI: antipsychotics
Pathology of frontotemporal dementia
genetic causes, trauma, alcohol
FT atropy, Pick bodies (tau proteins) Pick’s disease
Sx of frontotemporal dementia
<65yr onset, impulsive, irritable, crying, overweight, akinesia, hallucinatinos, parkinsonism later
