Geriatrics Flashcards
In Geriatrics, what is the most common definition of multimorbidity?
2 or more chronic medical conditions
The prevalence of multimorbidity in the geriatric population increases with the presence of which 3 factors?
Increasing age, socioecenomic deprivation and female gender
What is the definition of hyper-polypharmacy?
15 or more medications
Most people die from chronic diseases that progress along one or three typical illness trajectories. Name these.
Cancer (short decline), non-malignant organ failure (intermediated decline with acute episodes), frailty and dementia (gradual dwindling)
True or false? In States with voluntary assisted dying, the process for requesting this by the patient is separate from, and cannot be included in advanced care planning or palliative care
.True
Name the 3 major transition points of care along any illness trajectory (with regards to palliative care)
- Early identification of palliaitve care needs and initiation of a palliative approach, 2. Reassessment of palliative care needs and initiation of end-of-life-care plan, 3. Identifying dying and initiation of terminal care plan, planning for after-death care and bereavement support
What is the doctrine of double effect?
Law that recognises that giving medicines to a patient to relieve pain is lawful, even it it could hasten death
What is the recommended timeframe suggested for deprescribing long term benzodiazapines?
Very slow weaning program 10-15% per week. Sudden withdrawal may results in confusion, hallucinations and seizures.
What is the risk of suddenly deprescribing beta-blockers?
Can exacerbate angina or precipitate rebound hypertension, MI or ventricular arrythmias
What specific risk is associated with sudden deprescribing of levodopa?
Neuroleptic yndrome
What is the risk of suddenly deprescribing a PPI?
Hypersecretion of acid and aggravation of symptoms
What is the definition of polypharmacy?
The use of 5 or more drugs - including prescription, OTC, complementary and alternative medicines
What does the ‘prescribing cascade’ refer to?
Contributes to polypharamcy, where one medicine is begun to treat the adverse effects of another
List at least 6 medicines which should be used in caution with older people
Amiodarone, anticholinergics, antihistamines, pntispychotics, aspirin for primary prevention in people ages > 80, benzos, diuretics, fluoxetine, methyldopa, nitrofurantoin, NSAIDs, TCAs
What does ‘undiagnosis’ refer to in geriatric prescribing?
A process which facilitates the withdrawal of corresponding medicines used to manage conditions which are no longer relevant
List the 4 main discrete types of dementia
AD, vascular, frontotemporal, dementia with Lewy bodies
State the diagnostic criteria for dementia, as per the DSM V.
Major neurocognitive disorder - evidence of significant cognitive decline in 1+ cognitive domains (complex attention, executive function, learning, memory, language, perceptual motor or social cognition), based on concern of the individual, a knowledegable informant or clinician. Interferes with independence in every day activities, not because of delirium and not better explained by another mental disorder
List the 6 steps that are required for a GP to diagnose dementia
Cognitive function test, pathology tests, imaging, assessment for depression, medication review, functional assessment
List at least 3 cognitive function tests for the diagnosis of dementia, as recommended in the RACGP red book
Standardised mini mental state (SMMSE), GP assessment of cognitition (GPCog), Clock drawing test, Rowland universal denetial assessment scale (RUDAS), Kimberley indigenous cognitive assessment (KICA), modified KICA
List the pathology tests required in the diagnosis of dementia (to exclude medical cause of cognitive decline)
CBE, biochemistry with electrolytes, calcium, glucose, UEC, LFT, TFT, B12, folate (syphillis and HIV can be considered in specific cases)
Which imaging investigation is required for the workup of dementia?
At least CT brain to exclude tumour/SDH etc., and CXR may be needed to rule out chest pathology causing a delirium
True or false? ANtidepressants do not work well for depression in the presence of dementia
True. A trial of antidepressants may be warranted if depression seems to be the cause of cognitive decline. However, in patients with dementia AND depresssion, these medications don’t work well for the depression but can be helpful for agitation
Which class of antidepressants are commonly recommended for patients with dementia? Which is the most effective?
SSRIs (ciralopram the most effective) - start with half the usual adult dose and increase as tolerated
When commencing an antidepressant for a patient with dementia, what should be assessed after a fortnight?
Serum sodium, as can cause hyponatraemia
True or false? Endep is one of the antidepressants recommended for patients with dementia
False - highly anti cholinergic antidepressants should be avoided because of their adverse effect on cognition
There is growing evidence for which secondary prevention strategies in dementia?
Mediterranean diet, regular exercise and social contact - may alleviate symptoms and slow progression
Name the 3 medications that are used to manage symptoms of dementia. What class of drug do these belong to?
Donepazil, rivastigmine, galantamine. Acetylcholinesterase inhibitors.
In which type of dementia should acetylcholinesterase inhibitors not be used and why?
FTD because of severe side effects and potential to exacerbate BPSD
What are the prescribing requirements for acetylcholinesterase inhibitors in Australia for dementia?
Initial prescription on PBS for AZ, must be prescribed in consultation with a geriatrician or psychiatrist. To continue, need evidence of clinical improvement during the first 6 months
Explain why an ECG should be done at baseline for any patient with dementia who is being prescribed an acetylcholinesterase inhibitor
Because heart block is a rare but serious adverse event
List at least 5 adverse effects of acetylcholinesterase inhibitors
NAusea, vomiting, diarrrhoea, dizziness, increased urinary incontinence and frequency, falls, muscle cramps, weight loss, anorexia, headache, insomnia
What type of medicine is mementine and when may it be used?
NMDA receptor antagonist, which may be used for moderate to severe alzheimers
Name the 3 models of BPSD in dementia
- Unmet need, 2. Loweres stress threshold, 3. Biological model
Antipsychotic medication can be effective in BPSD, particularly for behaviours that have been precipitated by ______
Hallucinations/delusions
List at least 4 specific indications for antipsychotic medications in the elderly
Depression, anxiety, psychotic symptoms, motor activity and aggression - or “those with BPSD who cause significant distress to themselves or others”
Name at least 2 important side effects to carefully monitor for when starting and older person on an antipsychotic medication
Sedation, postural hypotension and Parkinsonism
In what situation is it appropriate to prescribe an antipsychotic as a PRN order for older people?
Only when weaning - it is discouraged at other times
Which antipsychotic has been approved by the PBS for the management of BPSD? How often should this medication be reviewed?
Risperidone, review every 1-3 months
List the pros and cons of Risperidone compared to other antipsychotics for the management of BPSD
Fewer seriour adverse seide effects overall and is better tolerated, but can cause extrapyrimydal side effects, drowsiness, hypotension, hyperglycaemia and increased risk of CVA
Why are conventional antipsychotics (i.e., haloperidol) not recommended for the treatment of BPSD?
Because of lack of evidence and common occurrence of extrapyrimydal side effects and sedative anticholinergic side effects (cannot be used in patients with LBD or Parkinson’s)
List the pros and cons of using benzodiazepines in patients with BPSD
Can exacerbate cognitive impairment and increase the risk of falls and injury, but can sometimes be helpful in severe anxiety and agitation. Oxazepam is the benzo of choice.
What is the benzodiazepine of choice in BPSD and why?
Oxazepam, due to its short half-life and uncomplicated metabolism
Give at least 4 examples of behviours in BPSD which do not respond to antipsychotics
Undressing in public, calling out, restlessness, day-night reversal, inappropriate voiding or verbal aggression
True or false? Long term use of benzodiazapines can lead to long-term cognitive impairment and risk of dementia
.True
When initiating an antipsychotic for BPSD, what review schedule should be actioned?
Start at lowest dose, review within 1 week and set a reminder to review in 12 weeks with a plan to weane and cease if possible (good evidence that people won’t need long-term because the nature of BPSD is variable and symptoms can be intermittent and settle spontaneously)
Who can be called to for advice about BPSD?
Dementia Behaviour Management Advisory Service (DBMAS), or Severe Behaviour Response Team (SBRT)
To prescribe anti-resorption drugs for OP on the PBS, which criteria need to be met?
BMD with T score
Why are calcium and vitamin D important in the management of osteoporosis?
They are a preventative strategy in themselves, but there is also a risk of hypoclacemia during treatment if dietary calcium or Vit D stores are low
What stratergy can be used to avoid hypoclacemia when initiating denosumab for patients in RACF?
Replace Vit D and calcium prior to initiation, and monitor serum calcium 7-10 days after starting
When assessing chronic pain, what is the difference between baseline pain, flare up (intermittent) pain and incident pain?
Baseline pain is experienced constantly for longer than 12 hours/day. Flare-up pain is transient period of increased pain, and incident pain is that which occurs during an acitvity (i.e., turning in bed)
True or false? Chronic pain in the elderly is a condition in it’s own right and does not need to be secondary to a cause
.True
What is the origin of stimulus in nociceptive superficial pain? Give an example
Skin, subcutaneous tissue, mucosa of the nose/mouth/sinuses/urethra/anus. Examples includes pressure ulcers and stomatitis
What are the classical characteristic descriptions of nociceptive superficial pain (descrption, localisation, movement, referral, location, autonomic effects)
Hot, burning, stinging, does not refer. Local tenderness is present and is not affected by movement. No autonomic features are present
What is the origin of stimulus in nociceptive deep somatic pain? Give an example
Bone joints, muscles, tendons, ligaments, superficial lymph nodes, organs and capsules, mesothelial membranes. Examples are arthritis, liver capsule distension or inflammation
What are the classical characteristic descriptions of nociceptive deep somatic pain (descrption, localisation, movement, referral, location, autonomic effects)
Dull and aching, well defined to location of stimulus with local tenderness, worsening pain with movement, refers to other areas, no autonomic effects
What is the origin of stimulus in nociceptive visceral pain? Give an example
Solid or hollow organs, deep tumour masses, deep lymph nodes. Examples deep abdominal or chest masses, intestinal, biliary ureteric colic
What are the classical characteristic descriptions of nociceptive visceral pain (descrption, localisation, movement, referral, location, autonomic effects)
Dull and deep, poorly defined to the location of the stimuli, may have local tenderness. May improve with movement. Often refers. Autonomic features include nausea, vomiting, blood pressure and HR changes
What is the origin of stimulus in neuropathic pain? Give an example
Damage to nociceptive pathways. Examples: tumour related like brachial plexus tumours, chest wall invasion, spinal cord compression. Non-tumour related examples are postherpetic neuralgia, phantom pain etc.
What are the classical characteristic descriptions of neuropathic pain (descrption, localisation, movement, referral, location, autonomic effects)
Dysaesthesia with pins and needles, tingling, burning, lacinating, shooting. Can present with allodynia, phantom pain, numbness. Presents along the nerve or dermatome distribution. Nerve traction provokes pain. Tends to refer. Can be local tenderness. Autonomic instability including warmth, sweating, pallor, cold, cyanosis (all localised to the nerve pathway)
List the 3 types of pain assessment tools which can be used in RACFs
Self-report tools, observational behavioural tools and sensory testing tools
Which type of pain assessment tool is the gold-standard?
Self-report tools
Give at least 2 examples of physical therapies that a physiotherapist may recommend for pain in an older person
TENS, walking programs, strengthening exercsies and massage
Simple explain why foot orthotics can be helpful in the treatment of pain in older persons
Can change gait pattern and muscle activation and reduce joint loading
Explain why about 10% of people will not get analgesic benefit from codeine
Because these people lack the enzyme to covert codeine to active opioid form
What is the mechanism of action of tramadol?
Centrally acting analgesic, acts weekly on opioid receptors, inhibits noradrenaline and serotonin reuptake
What is the long-acting form of oxycodone?
Oxycontin
What is the preferred transdermal medication for older people with chronic pain?
Buprenorphine patches, slow release and safe in renal ailure and older people. Fentanyl patches should be reserved for ongoing severe pain, because it is very potent and long acting and thus the risk of relirium and respiratory depression is high
List some of the side effects of tricyclic antidepressants
Anticholinergic side effects including postural hypotension, sedation, constipation, urinary retention
In what setting may anticonvulsants such as carbemazapine be considered for pain management in older people?
For those with trigeminal neuralgia (with careful titration over time)
What side effects may occur with sudden withdrawal of pregabalin?
Anxiety, insomnia, headache, nausea and diarrhoea
For support of skin barrier function and connective tissue health and cell repair, what dietary factors should be encouraged in the elderly?
Zinc, Cit D, Vit C, adequate protein
Explain the changes in skin physiology that results in older people being more prone to heatstroke
The skin has reduced ability to sweat, and there is less surface area of blood vessels
Explain the changes in skin physiology that results in older people being more susceptible to cold
Thinning of subcutaneous fat
Explain why bruising is more common in older adults
Physiological loss of connective tissue and increasing blood vessel fragility, leading to less resistance to shearing forces and less resilience of the skin to knocks and scrapes (often worsened by NSAIDs, aspirin and blood thinners). These shearing forces in skin with loss of elasticity is also the cause of skin tears
What are the mainstays of treatment for senile pruritis?
Symptom relief with cold compresses supplemented by non-sedating antihistamines (and treating underlying causes)
Simpley describe the management of a skin tear in an older person
Where possible, the patient’s own skin flap should be used as a graft - after cleaning the area, the flap should be laid back in place and held in contact with the wound bed by using a firm dressing for several days
What should be considered in wounds or ulcers in the elderly that are clinically infected and non-healing?
Biopsy of the wound edge or a swab - cutaneous cancers can present in this way
List 2 types of medications that can result in SJS
Allopurinol, sulphur-based medications
What drugs are first-line in the treatment of anxiety in older people?
SSRIs and SNRIs
What is the diagnostic difference between mania and hypo mania?
Hypomania symptoms need to be present for at least 4 days, and 7 days for mania
The DSM V states that a diagnosis of schizophrenia can only be made with 2+ of the following has occurred for at least a month (name them) + one of the minor criteria (name them)
Major criteria: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms. Minor: impairment in work/relationships/self care, lasting for continuous 6 months, other causes ruled out
True or false? The presence of dementia itself is associated with a 50% higher risk of sepsis
.True
True or false? Fever may not be present in older people with sepsis
True - therefore a change in baseline should warrant attention
Give 2 examples of causes of fever in older people, aside from sepsis/infection
Gout, polymyalgia rheumatica
In which situation should an older person be treated for a UTI if they have an in-dwelling catheter?
Only if they have systemic symptoms/signs (as bacteruria is common in these patients)
Which 2 viruses are the most common causes of gastroenteritis in RACFs?
Rotavirus and norovirus
List at least 3 physiological parameters that are signifiantly impaired in those older people who experience recurrent falls
Reaction time, body sway, quadricept strength, virbration sense, visual contrast sensitivity
Comment on the quote mortality rates from hip fracture in older people
10% die within 1 month, 20% within 6 months and 33% within a year. Only 20% regain full mobility after a fall
List some of the consequences for older people who have a long lie following a fall
Hypothermia, bronchopneumonia, dehydration, pressure injuries, rhabdomyolysis and death
Explain what a positive Rhomberg’s test means
Test of proprioception, and a positive test is caused by proprioceptive dysfunction or vestibular dysfunction. If a person is unable to keep their balance when their eyes are closed, this means they have been using vision to compensate for the lack of sensory feedback received from the lower extremities (most people with cerebellar lesions won’t be able to maintain posture with visual cues)
Describe the timed up and go test for falls risk
Patient is instructed to stand, walk 3m, turn around and walk back and sit down. Most people will be able to do this in 10 seconds
What is frailty?
A sryndrome of physiological decline that occurs later in life and is associated with vulnerability to adverse health outcomes
List at least 5 risk factors associated with increased frailty
Older age, current smoker, lower educational level, use of HRT, depression, intellectual disability, ATSI, under nutrition, sedentary lifestyle, chronic disease, obesity
Decline in skeletal muscle function and mass in older people is a consequence of what changes?
Age-related hormonal changes and changes in inflammatory pathways (including inflammatory cytokines)
The following hormones all decrease with age, except for which one? Growth hormone, IGF-1, DHEA-S, cortisol, sex stroids, 25 (OH) Vitamin D
Cortisol
How does decreasing DHEA-S (dehydroepiandrosterone sulfate) contribute to frailty in older age?
Plays direct role in maintaining muscle mass and prevents activation of inflammatory pathways that contribute to muscle decline
There is evidence of strong correlation between frailty and bio markers of the innate immune system. Give some examples
Levels of pro-inflammatory IL-6 and CRP are elevated in older adults, and ILD-6 adversely affects skeletal muscle, appetite, adaptive immune system function and contributes to anaemia
True or false? There is an association between frailty and clotting markers
True - Factor VII, fibrinogen and D-dimer
List the 2 models of frailty
Frailty phenotype model (underlying biological basis) and Frailty Index (cumulative deficit model)
List at least 3 interventions for frailty that have some efficacy
Exercise (resistance + aerobic), caloric and protein support, Vit D supplementation if deficient, reduction in polypharmacy
List at least 4 age-related changes in the urinary tract system that leave older people more susceptible to urinary incontinence
Reduced bladder capacity, reduced sensation of filling, increased detrusor activity, decreased bladder contractile function, increased incidence of benign prostatic obstruction in males, decreased urethral closure pressure and circulating oestrogen in women
What is mixed urinary incontinence, and in which patients may this occur?
Combination of urge and stress incontinence. E.g., women with pelvic floor weakness that leads to idiopathic detrusor overactivity, or men who develop these symptoms following radical prostatectomy
List the 5 categories of urinary incontinence
Stress, urge, mixed, overflow (chronic retention) and functional
Which medications can be cause or aggravate urge incontinence?
Diuretics, SSRIs, cholinergics and anticholinesterase agents
Which medications can be cause or aggravate stress incontinence?
Alpha-adrenergic blockers
Which medications can be cause or aggravate overflow incontinence?
Anticholinergics, verapamil, pseudoephedrine, opioids, many psychotropics
List 3 basic investigations for urinary incontinence
Urine MCS, bladder chart over 3 days, portable bladder scan for post-void residual urine (or formal US KUB if not available)
If possible, which lifestyle advice should be given to older patients with urinary incontinence?
Limit fluids to 1.5L/day and limit alcohol and caffeine; minimise evening fluid intake and ensure adequate night lighting for nocturia; avoid/treat constipation; regular toileting with good posture; bladder retraining for urge incontinence; pelvic floor training for stress incontinence; incontinence products; mobility aids
What is the only PBS funded medication for overactive symptoms?
Oxybutynin (anticholinergic)
List at least 1 non-PBS medication which can be used for urinary incontinence
Solifenacin, darifenacin, mirabegron
Explain why solifenacin or darifenacin may be better tolerated to oxybutynin
Fewer anticholinergic side effects because of the targeted actions on the M3 muscarinic receptors in bladder smooth muscle
State the side effects of oxybutynin
Anticholinergic - xerostomia, constipation, worsening urinary retention, cognitive impairment
What kind of medication is mirabegron, what are the risks and benefits of using this for urinary incontinence?
Beta-3 adrenergic receptor agonist that does not have anticholinergic side effects (good in cognitive impairment). Side effects include increase in BP - contraindicated in severe uncontrolled HTN
List the medications which may be considered to treat bladder outlet obstruction related to prostatic enlargement due to BPH
Prazosin (lowers BP and can increase falls risk), dutasteride with tamsulosin (preferred in geriatrics), tamsulosin alone (DVA but not PBS)
What is the definition of overactive bladder syndrome?
Storage symptoms of urgency with or without urgency incontinence, usually with frequency and nocturia
What is the definition of detrusor overactivity?
Diagnosis made on urodynamics testing confirming involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked
What is the definition of nocturia?
Interruption of sleep one or more times at night to void
What is the definition of nocturnal polyuria?
> 33% of the total daily urine production occurring at night
What are the ‘storage’ LUTS?
Frequency, urgency, nocturia
What are the ‘voiding’ LUTS?
Hesitancy, poor stream, incomplete emptying, post-void dribbling
What is the difference between faecal incontinence and anal incontinence?
Faecal incontinence is the involuntary loss of faeces at an inappropriate time/place. Anal incontinence includes faecal incontinence as well as involuntary loss of flatus
List at least 4 risk factors for faecal incontinence in the elderly
Female gender, coexisting urinary incontinence, high BMI, loose stool consistency, prior colorectal surgery, age-related reduction in sphincter tone at rest
What is meant by the biology of aging?
Progressive accumulation of random molecular defects that accumulate in tissues and cells, which eventually results in age-related functional impairment of tissues and organs
List 3 results of oxidative damage to cells
- Damage to nuclear chromosomal DNA, 2. Shortening of telomeres, 3. Mitochrondrial DNA and lipid peroxidation (resulting in reduced cellular energy production and eventually cell death)
Explain simply why chronic inflammation causes cellular damage
Drives the production of reactive oxygen species produced during metabolism of oxygen to produce cellular energy
What is the result of age-related vessel stiffening?
Increases systemic vascular resistance and cardiac afterload, which leads to increased workload. In the venous system, this results in reduced compliance and the system having less capacity to buffer changes in intravascular volume
What age-related physiological change is responsible for lengthened contraction time of myocardium in older age?
Hypertrophy of myocytes
With aging, how much does the intrinsic heart rate fall?
About 5-6 beats per minute per decade
Which intracerebral deposits occur in normal aging?
Neurofibrillary tangles and senile plaques (amyloid)
In age-related changes of the autonomic nervous system, parasympathetic outflow ____, whilst sympathetic tone ______
Decreases, increases
WIth aging, what is the expected decrease in creatinine clearance?
10mL/min every decade
Creatinine clearance is influenced by what factors?
Nutritional status, protein intake, muscle mass and body weight
Name the 4 geriatric syndromes that allow doctors to define ‘illness’ presentation of geriatric patients, which acknowledges that the traditional model of care does not often apply to the geriatric population
Frailty, sarcopaenia, anorexia of aging, cognitive impairment
Name the tool that can be used to develop a management plan for the geriatric patient who presents with a syndrome of aging
The 5M tool (mind, mobility, medications, multi complexity, matters most)
What is the most common definition of multimorbidity?
The presence of 2 or more chronic diseases in an individual
List at least 3 concepts of ‘health aging’
Need for independence, autonomy, purposeful and meaningful existence, and the opportunity to participate and contribute in the community
Name the 5 principles of effective teamwork and collaboration in healthcare
Shared goals, clear roles, mutual trust, effective communication, measurable processes and outcomes
List at least 4 underlying factors that lead to increased vulnerability for medication adverse/side effects in older people
Reduced body water, increased body fat, reduced protein binding, renal and hepatic impairment, increased receptor sensitivity, decline in compensatory mechanisms
List the 3 broad areas/domains of capacity
Personal, financial and health
What is the definition of intersex?
An unbrella term for people born with congenital, atypical sex traits
List at least 3 common intersex varaitions
Klinefelter syndrome (47XXY), Turner Syndrome (45X), congenital adrenal hyperplasia, androgen nsensitivity syndrome
Which cognitive screening tool has been validated in migrant populations?
RUDAS
List the groups of people who qualify for private standards when assessing fitness to drive
Class C licence holders (car), R (motorcycle), LR (light ridgid), UNLESS also applying for an authority to use the vehicle for carrying public passangers for hire, or for the carriage of bulk dangerous goods
What is the advice in regards to driving asfter a DVT or PE?
Not to drive for at least 2 weeks following a DVT, and 6 weeks following PE
What is the advice in regards to driving after AMI or CABG?
2 weeks for AMI, 4 weeks for CABG (PCI only 2 days)
What is the advice in regards to driving after cardiac arrest?
6 months
What is the advice in regards to driving after valvular surgery?
4 weeks
A person is not fit to hold an unconditional driver’s licence if they have BP over what value consistently?
200/110 (treated or untreated)
What is the definition of a ‘severe hypoglycaemic event’ as per the Aus Driving Standards?
Hypoglycaemia of sufficient severity such that the person is unable to treat themselves and requires an outside party to administer treatment
For a patient who has had a severe hypoglycaemic event, for how long following this even should they be advised not to drive?
At least 6 weeks
For patients with diabetes who are not on insulin, what are the medical standards for private vehicle licensing?
Generally can drive without restrictions but should have at least 5 yearly reviews
Which patients with diabetes need a Specialist to help assess fitness to drive?
Any patient on insulin, patients with hypoglycaemia unawareness, and most often for commercial licensing
True or false? Only divers of commercial vehicles are required to meet a hearing standard?
.True
True or false? Any patient with a diagnosis of dementia is considered unfit to hold an unconditional license
True - this is because of the progressive nature of the disease. Many will still be able to drive early on, but the majority will eventually pose unacceptable risk and will need to have their licence revoked. Therefore, regular review with a conditional licence is needed
Give an example of a situation in which a patient with a history of seizures may be fit to resume an unconditional licence
If seizure free for 5 years and not on anti-epileptics for 12 months
What is the ‘default’ standard for driving after a seizure?
May be fit to hold a conditional licence if there have been no seizures for 1 year
Most people with unruptured intracranial aneurysms will be able to hold unrestricted licences - with which notable exception?
Those with high risk of sudden symptomatic haemorrhage (giant aneurysms 15mm or greater in size)
What is the advice regarding driving after a stroke?
4 weeks for private drivers and 3 months for commercial drivers
There is specific evidence of increased driving risk in patients with which 2 psychiatric conditions?
Schizophrenia and personality conditions
List some characterstics that make sleep apnoea more likely
Neck circumference (>42cm in men and 41cm in women), witnessed apnoea, daytime sleepiness, BMI > 35, crowded oropharynx, difficult to control T2DM and HTN
When testing visual acuity, how many errors are regarded as a ‘failure’ to read a line?
More than 2
State the visual acuities that quality for an unconditional licence - both private and commercial
Incorrect visual acuity. Private - with one or both eyes at least 6/12. Commercial - better eye at least 6/9 and worse eye at least 6/18
Patients should be referred for an eye examination if their visual acuity is less than ______ - for the purposes of being assessed to hold a conditional licence
If vision less than 6/12 with one or both eyes (or commercial licence holders with less than 6/9 in the better eye or 6/18 in the worse eye
Quote the normal visual fields, as set out by the Aus Driving Guidelines
60 degrees nasally, 100 degrees temporally, 75 inferiority and 60 superiorly (and binocular field extends these significantly)
Which crude test is acceptable when screening for visual field defect in a patient with no clinical indication of a visual field impairment or progressive eye condition?
Confrontation
True or false? Monocular vision is a contraindication to holding a private vehicle licence
False - a conditional licence may be considered if the horizontal visual field is 110 degrees and the acuity is satisfactory in the better eye
What is the minimum time a person should be advised not to drive if they develop sudden onset loss of vision?
Usually 3 months
What is the most common type of dementia?
Alzheimer disease (60%)
List some of the common features of Alzheimer disease
Slowly progressive onset of memory and language impairment, reduced executive functioning (ability for complex thought and decision making) with possible dyspraxia and agnosia
Lewy body dementia presents with at least 2 of which 3 features?
Fluctuating impaired cognition, visual hallucinations and parkinsonism
A MMSE score of less than __ is suggestive of cognitive impairment and often dementia
24
The MMSE is best utilised in what setting?
To monitor the effects of response to dementia treatment
Which validated tool may be used to help to differentiate between dementia and depression?
The Geriatric Depression Scale (GDS)
What are the 2 main reasons for ordering non-contrast CT brain in a patient as part of the workup of dementia
To exclude inter cerebral lesion (i.e., neoplasm or subdural), and for diagnosis - can aid in the differentiation of dementia type
True or false? There are currently no drugs proven to modify the neuropathology of dementia once established
.True - cholinesterase inhibitors can improve cognitive function and/or delay the rate of cognitive decline in mild to moderat AD
Name the 3 cholinesterase inhibitors on the PBS for patients who meet the criteria for subsidised treatment for dementia
Donepazil, Galantamine and Rivastigmine (Memantine is also on the PBS for people who don’t tolerate cholinesterase inhibitors)
What is the general advice for prescribing antipsychotics for patients with BPSD?
Avoid whenever possible, as the evidence is limited. If prescribing, review regularly. If symptoms resolve, reduce the dose after 2-3 months and stop all together if symptoms do not return. If there is no efficacy, stop treatment after 1-2 weeks
Give some examples of BPSD that will not respond to pharmacotherapy
Wandering, undressing, urinating inappropriately, shadowing staff or calling out - these are behaviours which a specific history must be taken in order to elicit contributing factors (often expressions of unmet needs)
Name the only drug that is subsidised for the treatment of psychotic symptoms and agression in Alzheimer Disease
Risperidone (and restricted duration of 12 weeks)
List some of the increased risks associated with prescription of antipsychotic drugs to patients with dementia
Increased risk of hospitalisation, falls, CVA and death
What is the evidence-based recommendation for treatment of depression in people with dementia?
The role of antidepressants is uncertain. However, people with dementia who have a history of MDD prior to dementia onset should be treated in the usual waa
Compare which groups of patients with dementia show evidence of positive outcomes with acetylcholinesterase inhibitors
Improve cognitive functioning and independence of ADLs in mild - moderate dementia (must be confirmed by a specialist to access PBS). Recent evidence of positive outcomes in LBD, Parkinson Dementia, VD and severe Alzheimer. Not helpful in MCI
What is the evidence for acetylcholinesterase inhibitors + memantine in dementia?
The combination has been shown to improve cognition and reduce symptoms such as distress and agitation - however, not on PBS. If benefit demonstrated, can access PBS after 6 months
What is the ‘ABC’ approach for assessing symptoms of challenging behaviours in dementia?
Antecedents; behaviour description; consequences. This is a way of assessing the symptoms and whether there is an unmet need that can be addressed
Which dementia subtype should NOT be prescribed antipsychotics?
Demential with Lewy Bodies - due to the high risk of extrapyrimydal side effects
State the diagnostic criteria that make up the ‘frailty phenotype’
3+ of unintentional weight loss, exhaustion, weakness, slow walking, low physical activity
Give some examples of drugs which need to be graduallu weaned if deprescibing is being undertaken in a frail geriatric patient
Those which cause adverse drug withdrawal events such as CNS active medicines, beta blockers and corticosteroids
Give an example of when a statin may be appropriate to deprescribe
May be considered when potential benefits (secondary prevention of CV events and death in patients with coronary heart disease) are no longer clinical relevant. E.g., patients with severe physical or cognitive impairments or those in their last year of life.
What is the current evidence for deprescribing antihypertensives in the elderly?
No good evidence that patients over the age of 80 experience reduction in overall mortality. Studies have shown cessation can be done safely without withdrawal effects - in addition many patients remain normotensive 6 months - 5 years after cessation with no increase in mortality
What considerations should be made when reviewing to cease sulfonylurea mediations in the elderly?
The benefit is of recuding microvascular complications over decades, so this may not be important in older frail adults. In addition, the risks of hypoglycaemia increase with age, and national guidelines recommend a higher target blood sugar for older patients
List the 2 broad levels of home support available in Australia
Commonwealth Home Support Programme (CHSP) for people with less complex needs, i.e., MOW/cleaning/short term physio. Home Care Packages (HCP) for those with more complex needs, require ACAT assessment to access
What option is available in Australia for an elderly patient who does not have a CHSP or HCP, who has not had an ACAT assessment but who requires urgent support?
Can refer directly to local care provider - the services provided are time limited and will need an ACAT if the care needs to be extended
List some of the key intrinsic risk factors for falls in the elderly
Age, sensory decline, reduced lower limb strength, cognitive impairment, comobidity
What are the strongest predictors of falls risk?
Previous falls, with injurious falls and walking or balance difficulty increasing the risk even further
List 2 tests that can be used to screen older people for balance deficits when assessing falls risk
Single leg stance test, timed up and go test
What is the single leg stance test?
Observe patient standing on one leg with eyes open for 10 seconds for 3 trials. 1 = completed 3 trials; 2 = completed 1 or 2 trials; 3 = completed no trials. A score of 2 or 3 indicates significant sensory and strength impairment
What is the times up and go test?
Patient stands from sitting, walks for 3 metres and then turns and returns to sit in the chair. Time of 15+ seconds identified those with a high risk of falling
What sort of exercise reduces falls risk is older adults living in the community?
Challenging balance exercise for 2 + hours per week on an ongoing basis (Tai Chi or Otago Exercise Program)
True or false? Daily Vit D supplementation prevents falls and fractures in those with Vit D < 60 regardless of the setting in which they live
.True
List some of the effective single interventions that have been proven to reduce falls risk
Benzo withdrawal, OT home mods, expedited cataract surgery, restricted multi focal outdoor use for active adults
List at least 3 characteristics of an effective exercise program to reduce falls risk
Moderate or high challenge balance, 2 hours per week on ongoing basis, home or group setting, optional strength training has cognitive and functional benefits. Brisk walking is NOT recommended for high risk individuals
Which strategies have good evidence for treating insomnia in older adults?
CBT and sleep restriction, melatonin is also supportive and does not results in next-day impairment or rebound insomnia
Describe the approach to weaning/ceasing long-term benzodiazepines in older adults (i.e., as a falls reduction strategy)
Transfer to equivalent diazepam dose, following by dose reduction of 25% per week over 5 consultations. Melatonin can also be used to support sedative withdrawal.
What is the only known contraindication to Vit D supplementation in RACF patients?
Hypercalcaemia
When should Vit D monitoring be undertaken for RACF patients?
Never, not needed
What is the alternate step test?
Measures how quickly an older person can alternate steps onto a 18cm step, total 8 times. A time of greater than 10 secs indicates increased falls risk
Which is the only single exercise intervention shown to reduce the risk of falling?
Tai Chi (although doesn’t reduce falls rate) - no other single category of exercise is effective on it’s own
List at least 3 risk factors for asymptomatic bacteruria in the elderly
Institutionalised or hospitalised patients, diebtes, cognitive impairment, structural urinary tract abnormalities and in dwelling catheters, increases with increasing age, history of stroke
What is the proposed reason for asymptomatic bacteruria increasing in prevalence in men 90-103 years of age?
Reduced bactericidal activity of prostatic fluid
What is the proposed reason for asymptomatic bacteruria increasing in prevalence in women with increasing age?
Reduced oestrogenand increased vaginal pH from lack of lactobacilli colonisation post-menopause, thereby predisposing women to colonisation by uropathogens
Give at least 2 examples of gram negative bacteria that can cause asymptomatic bacteriuria
e coli, klebsiella pneumonia, proteus mirabilis
Give at least 2 examples of gram positive bacteria that can cause asymptomatic bacteriuria
Enterococcus faecalis, coagulate negative staphyloccus and group B streptococcus
Give some examples of pathogens which are commonly found in long term catheter patients
Pseudomonas, morganella morganii and Providencia stuartii
What is the most common pathogen associated with asymptomatic bacteriuria? For institutionalised patients, what is the most frequently isolated pathogen?
E coli; proteus mirabilis
Describe the mechanism by which structural urinary tract abnormalities (such as renal calculi) are thought to predispose to asymptomatic bacteriuria
Stones cause irritation and inflammation of the urinary tract mucosa, restricting urinary flow which leads to stasis and obstruction
Descibe the mechanism by which patients with Alzheimer dementia, Parkinson disease and CVD potentially predispose to asymptomatic bacteriuria
Due to their adverse effects on bladder motility and continence
Descibe the mechanism by which diabetes predisposes to asymptomatic bacteriuria
Causes neurogenic bladder, diabetic microangiopathy and impaired immune system from hyperglycaemia
List at least 5 pathological factors that are associated with the presence of asymptomatic bacteriuria
Diabetes, primary biliary cirrhosis, reduced mobility, catheter, constipation, urinary tract abnormality (calculi, BPH, high PVR), neurological disease inc. dementia and stroke
Explain why constipation may contribute to asymptomatic bateriuria
Chronic consiptation can induce progressive neuropathy in the pelvic floor causing retention. In addition, overflow incontinence can then cause perineal soiling which further increases the risk
Explain what urine dipstick is actually useful for
Useful as a ‘rule out’ test for urine infection if notices and leukoesterase are both negative (i..e, it has a high negative predictive value)
True or false? Positive leukoesterase in a urine dipstick is a good predictor of urine infection
False - positive leukoesterase correlates with the presence of bacteruria in only 50% of patients
Which groups of patients with asymptomatic bateruria should be treated?
Those with abnormal urinary tracts and those with persistent bacteruria 48 hours after catheter removal, genitourinary manipulation or instrumentation with a high probability of bleeding (TURP etc), pregnancy women
Treatment is recommended for symptomatic bacteriuria as defined by what factors?
Presence of bacteriaemia with the same organism, acute pyelonephritis, acute lower urinary tract symptoms or catheter trauma/obstruction
In Australia, the screening and treatment of bacteruria is not recommended, except in which 2 cases?
Pregnant women, and men about to undergo a urological procedure in which mucosal bleeding is expected
Explain why topical oestrogen and cranberry juice may play a role in preventing asymptomatic bacteruria
Ostrogen increases vagina, colonisation with lactobacilli and hence can potentially reduce the presence of uropathogens. Cranberry juice has been proposed to be bacteriostatic
What is the dagnostic criteria for asymptomatic bacteruria in men?
Single urine specimen with one isolated bacteria in count >100000
What is the dagnostic criteria for asymptomatic bacteruria in women?
2 consecutive urine specimens with isolation of same bacterial strain in count > 100 000
What is the dagnostic criteria for asymptomatic bacteruria in patients with catheters?
Singe catheterised urine specimen with one bacterial species isolated in count >100
What is the most specific genitourinary symptom of symptomatic UTI in RACF patients?
Acute dysuria
True or false? There is no indication to investigate or treat cloudy or malodorous urine in the absence of other signs/symptoms of UTI in RACF patients
True - these are not reliable signs of UTI and urinalysis and culture should be avoided
True or false? A post-treatment urine culture should be performed after antibiotic therapy in RACF patients
.False
For a RACF patient without acute dysuria, what are the diagnostic criteria for suspected UTI?
Must have at least 2 criteria, and at least 1 of these must be either fever or acute mental status change. The minor criteria include new/worsening urinary urgency, frequency, suprapubic pain/tenderness or incontinence, gross haematuria, renal angle tenderness
For a RACF patient with a catheter, what are the diagnostic criteria for suspected UTI?
Must have at least one criteria of fever, renal angle tenderness/pain, rigours without identified cause or acute mental status change
Before starting antibiotic therapy for UTI in a RACF patient, what should be done?
Ensure the patient is rehydrated. Delaying therapy to assess for symptomatic UTI does not lead to adverse outcomes
What is the classic triad of normal pressure hydrocephalus in the elderly
Urinary incontinence, gait disturbance and dementia (commonly referred to as wet, wobbly and wacky)
An 80 year old lady presents with memory loss, urinary incontinence and an ataxic gait. What is the most likely diagnosis?
Normal pressure hydrocephalus
What are the diagnostic criteria for delirium?
Must have BOTH acute onset with fluctuating course, AND inattention. And then at least 1 of diagnoranised thinking +/- altered level of consciousness (may be hypo or hyperactive)
