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lethargy, apathy, excessive sleeping, inattention, withdrawn, motor retardation, drowsy, unrousable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
Ix for frontotemporal dementia
MMSE
CT/MRI head
Mx for frontotemporal dementia
SSRI for depression
olanzapine for agitation/hallucination
Pathology of vascular dementia
many strokes/TIA
grey + white matter damage
RFs for vascular dementia
Hypertension
Diabetes
age
hyperlipidaemia
Sx of vascular dementia
sudden onset
stepwise deterioration
motor disorders
behavioural changes
cog impairment
Ix for vascular dementia
MMSE
carotid USS
CT/MRI head
Mx for vascular dementia
treat risk factors
cholinersterase inhibitors
What is osteoporosis and what are risk factors?
low bone mineral density
age, female, low mobility, low BMI, RA, long term corticosteroids
Inx for osteoporosis
FRAX
DEXA scan
T score
Z score
Mx of osteoporosis
Calcichew + bisphosphonates (1st line)
HRT, denosumab, raloxifene, strontium,
ranelate = alternatives
Inx of TIA
FAST
ROSIER
ABCD2
bloods, head CT <1hr onset
autoimmune + thrombophilia screen
head MRI
carotid USS
Urinary incontience pathology
age -> urethral atrophy, pelvic floor atrophy, prostatic hypertrophy
Causes of urinary incontinence
Reversible: delerium, UTI, DMT2, diuretics
Treatable: BPH, overactive bladder, stress incontinence
Environmental: toilet too far away
Inx for urinary incontinenec
urine dip, MSU
haematuria -> cytology + cytoscopy
FBC, U&E, LFT, glucose, TFT
bladder diary
mx of urinary incontience
overactive bladder: antimuscarincs and bladder retraining
dementia: regular toileting
stress incontinence: pelvic floor exercises
BPH: antiandrogens, surgery
hypotonic bladder: intermittent catheter
Nocturia: desmopressin (not for over 65s,)
A 75-year-old man with a background of epilepsy, well-controlled on sodium valproate, is admitted with urosepsis. He has normal renal function.
Which of the following antibiotics is important to avoid?
ciprofloxacin
reduces seizure threshold
If a pt is on 300mg oral morphine, unsafe swallowing, gets changed to Subcut morphine, what should dose be?
150mg
oral to subcut is 2:1
Use and common side effect of amitryptiline in elderly
chronic pain
Side effect: constipation
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. Which of these medications would be appropriate to give him as a painkiller?
tramadol or oxycodone
- can be used in dialysis pts
What do the deprivation of liberty safeguards (DOLS) refer to?
a means to protect the rights of pts who lack capacity who are detained in a hospital or care home
What do the deprivation of liberty safeguards (DOLS) refer to?
a means to protect the rights of pts who lack capacity who are detained in a hospital or care home
Important differential of dementia
pseudo dementia - aka depressive dementia
Features of pseudo dementia in an elderly pt
short duration of dementia
equal effect on long and short term memory
amnesia concerning specific events normally emotionally charged
detailed complaint about memory disturbance
pts highlight failures to answer questions relating to memory
loss of social skills early in illness
pts will often answer ‘don’t know’ to questions as opposed to guessing
pts may take little effort in performing tasks
1st line management of Alzheimer’s disease
Donepezil (acetylcholinesterase inhibitor)
Memantine is NMDA receptor antagonist - used if acetylcholinesterase inhibitor are CI or as an add on.
Mx of paracetamol overdose when within 8hrs ingestion and above treatment line
acetylcysteine
given in total dose divided by 3 consequetive IV infusions
1st is done over one hour
What are some seizure threshold lowering drusg
abx: imipenem, penicillins, cephalosporins, metronidazole, isoniazid
antipsychotics
antidepressants: bupropion, tricyclics, venlafaxine
tramadol
fentanyl
ketamine
lidocaine
lithium
antihistamine
Causes of falls in elderly
drugs (sedatives/alcohol)
MSK (OA hip)
Syncope (vasovagal, cardiogenic, arrhythmias)
Stroke/tia
Postural hypotension
vertigo
peripheral neuropathy or parkinsons
3 main features of Parkinsons
tremor
bradykinesia
rigidity (lead pipe, cogwheel)
3 differentiating features of a parkinsonian tremor
slow (pill rolling)
worse at rest
asymmetrical
reduced on distraction
reduced on movement
pathophysilogy of parkinsons
loss of dopaminergic neurons in substantia nigra
what class of drug is normally combined with L-dopa to prevent peripheral side effects for parkinsons
dopa decarboxylase inhibitor (carbidopa or benserazide
3 complications of L-dopa therapy (parkinsons)
postural hypotension
confusion, hallucinations
L-dope induced dyskinesia
What calculation tool to calculate risk of developing stroke in next few days in pt with TIA
ABCD2 risk of stroke post TIA
Prevention of pressure sores?
barrier creams
pressure redistribution and friction reduction
repositioning
regular skin assessments
name 4 cardiac conditions that may cause embolic CVA
AF
MI
Infective endocarditis
aortic or mitral valve disease
Mx of parkinsons
dopamine receptor agonist (bromocriptine, ropinrole, cabergoline)
can causes impulse control disorders
L-dopa
Causes of hyponatriaemia
heart failure, SIADH, NSAIDs
Addison’s disease, diarrhoea & vomiting
sx of hypocalcemia
parasthesia (fingers, toes, around mouth)
tetany
carpopedal spasms
muscle cramps
seizrues
prolonged QT
sx of hypercalacemia
bones, stones, moans and groans
bone pain
renal stones
drowsiness, poor concentration
nausea/vomiting, GI disturbance/discomfort
MMSE results of dementia (score)`
25-27 borderline
21-24 mild dementia
10-20 moderate dementia
<10 severe dementia
Mx for Alzheimer’s
donepezil (acetylcholinesterase inhibitor
Mx for severe Alzheimer’s
memantine
a N-methyl-D-aspartate-receptor antagonist
different types of delierum
acute fluctuating
hyperactive - agitation, inappropiate behaviour, hallucinaitions
hypoactive - lethargy, reduced concentration
How do bisphosphonates work
analougues of pyrophosphate,
inhibit osteoclasts
Clinical uses of bisphosphonates
prevent and treat osteoporosis
hypercalcaemia
paget’s disease
pain from bone mets
Causes of malnutrition
decreased nutrient intake
increased nutirent requirements: sepsis, injury
inability to utilise ingested nutrients (malabsorption)
combo of above
clinical features of re-feeding syndrome
arrthymia, hypotension
abdo pain, constipation, vomiting
muscle weakness
Sob
Mx of refeeding syndrome
replace electrolytes Po43-, potassium, magnesium
Componenets of mental capacity act
assume capacity
maximise decision making
freedom to make seemingly unwise decisions
best interests
least restrictive option
section 2 of MHA?
28days, not renewable
AMHP + 2drs
Section 3 of MHA
treatment
up to 6 months
can be renewed
Section 4 MHA>?
72hr assessment order
used in emergency
Section 5(2) MHA?
pt voluntary pt in hospital can be legally detained by a doctor for 72hrs
Section 5(4) MHA?
pt voluntary in hosp can be etained by a nurse for 6 hrs
section 135 MHA
court order, allow police to break into property to remove person to place of safety
Section 136 MHA
someone fuond in public place suspected of having mental disorder can be taken by police to place of safety
