Geriatrics Flashcards
WHat is a stroke?
•(cerebrovascular accident – CVA) = Rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24hoyrs or leading to death, with no apparent cause other than of vascular origin. sudden interruption in the vascular supply of the brain.
What is a transient ischaemic attacks?
•TIA – Transient ischemic attack – sudden onset of focal neurologic symptoms and/or sign lasting typically <1hours, brought on by transient decrease in blood flow. Causes are same eg, atherothromboemboiusm, cardioembolism, hypervsicosity, vasculitis. Check not hypoglycaemia, migraine aura, focal epilepsy etc. Do bloods, lipids CXR, ECG, doppler, poss angiography, C. Control RFs, antiplatelet drugs, anticoag factor, carotid endarectomy qithin 2w possible. Driving stopped for at least 1m. ABDE score for emergency referral (age, BP, clinical, duration symptoms, diabetes).
SYmptoms and signs of a stroke
•Symptoms + Signs: Sudden onset, Motor weakness (face/arm/leg weakness or sensory loss), loss coordination, speech problems (dysphasia-understanding/generation language, dysarthria, dysphonia), swallowing problems, visual field defects (homonymous hemianopia), balance problems. Dynamic phenomenon. Loss of function. Mostly UMN lesion but these symptoms aren’t immediate– so tone usually increases but this is gradual, brisk reflexes, clonus,
Cerebral hemisphere infarct symptoms
– Contralateral hemiplegia (flaccid then spastic), contralateral sensory loss, homonymous hemianopia, dysphasia
Brainstem infarct symptom
•– may result in more severe symptoms including quadriplegia and lock in syndrome.
Haemorrhages - signs/symptoms generally
•more likely to have decrease in level of consciousness, headache, nausea and vomiting.
Ischaemi vs haemorrhagic stroke
What is this
Intracerebral ahemorrhage
WHta is a TACI?
- Total anterior circulation infarct
- Invovles ACA + MCA
- Unilateral hemiapresis and/or hemisensory loss of face/arm/leg
- Homonymous hemianopia
- Higher cognitive dysfunction eg, dysphasia
PACI
- Partial anterior ciruclation infarcts
- Smaller arteries of anterior circulation
- 2 of:
- Unilateral hemiapresis and/or hemisensory loss of face/arm/leg
- Homonymous hemianopia
- Higher cognitive dysfunction eg, dysphasia
Lacunar infarct
- Involves perforating arteries aroudn internal capsule, thalamus and basal gnaglia
- 1 of following:
- Unilateral weakness (and/or sensory deficity) of face and arm, arm and leg or all three
- Pure sensory stroke
- Ataxis hemiparesis
Posteiror ciruclation infarct:
Vertebrobasillar arteries
1 of following:
- Cerebellar of brainstem syndromes
- Loss of consciousness
- Isolated homohymous hemianopia
Symptoms of anterior cerebral artery stroke
Contralateral hemiparesis and snesory loss, lower extremity >upper
Symptoms middle cerebral artery stroke
- Contralateral hemiparesis and sensory loss, upper extremity> lower.
- Contralateral homonymous hemianopia, aphasia
Posterir cerebral artery stroke symptoms
Contralateral homonymous hemianopia wit muscular sparing. Visual agnosia
Webers syndrome (branches of posterior cerebral artery that supply midbrain)
Ipsilateral CN III palsy
Contralateral weakness of upper an dlower extremities
Posterior inferior cerebellar artery stroke (lateral medullar syndrome, wallenberg syndrome)
Ipsilateral: facial pain and temp loss
Contralateral limb/torso pain and temp looss
Atai, nystagmus
Anterior inferior cerebellar artery (lateral pontine syndrome) stroke symtpoms
SYmptoms similar to Wallenbers but ipsilateral facia apralyis and deafness
- Ipsilateral: facial pain and temp loss.
- Contralateral limb/torso pain and temp loss.
- Ataxia, nystagmus
Retinal/opthalmic artery stroke
Amaurosis fugac
Basilar artery storke symptoms
Locked in syndrome
Investigations in stroke
- CT first - see if ischaemic or haemorrhagic
- MRI might be later for diagnostic
- Also - ECG, CXR, Bloods etc. Can do carotid imaging (carotid USS) to see if need carotid endararterectomy
- Acute ischaemic stroke - may show areas of low density in grey and white matter which can take time. Also could show hyperdense atery sign corresponding with artery cot
- Acute haemorrhagic stroke - hyperdense material (blood) surrounded by lower densoty (oedema)
Subarachnoid vs subdural vs epidural on CT
Management of strokes
•Management: maintain homeostasis (blood glucose, bp), screen swallow, ct/mri within 1hour, antiplatelets, thrombolysis, thrombectomy. .
•Ischaemic – thrombolysis if criteria met. Within 4.5 presentation, no previous ICH, uncontrolled hypertension, pregnant etc. Once hemorrhagic excluded then 300mg aspirin ASAP and continue antiplatelet therapy.
•TIA = <24h. Give aspirin 300mg immediately unless contraindicated (if taking anticoag etc or exclude haemorrhage). If has had more than 1 TIA or cardioembolic source or severe carotid stenosis then discuss admission with storke specialist. If within last 7days suspected then urgen assess with stroke Dr within 24hrs and if more than a week ago then specialist assessment within 7days if possible with stroke Dr
•Haemorrhagic stroke – neurosurgical consultation. Most not suitable for surgery. So supportive Tx. Anticoags and antithrombotics should be stopped to minimize bleeding. If anticoagulated then reverse as quickly as possible and try reduce BP (evidence)
Primary vs secondary prevention in strokes
- Primary - look for and treat HTN, DM, Hyperlipiedmia, cardiac disease, af
- Secondary - control RFs, mainly lower cholesterone, BP. Antiplatelets after stroke. Bleeding scores.
Complications of infarct
- Haemorrhagic transformation
- Malignant MCA syndrome - cerebral oedema so need hemicraniotomy
- Seizure
- DVT/PE
- Aspiration pneumonia
- Pressre sores
- Spasticity
- Pain
- Increased falls risk
- Continence problems
- Depression
Thrmbolysis in stroke management
- Aspirin and anticoag treatment
- Thrombectomy - For ischemic stroke (clot in big artery). Intervention neuroradiological procedure. After confirm stroke <6h with NIHSS>6 CT head excludes other things and CTA confirms large vessel occlusions… Normally thrombolysis unless contra-indication. Before. Femoral access. Try aspiration to suck out clot or stentriever
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Thrombolysis isn’t always good – risk of bleeding in haemorrhage hence time cut off. SO <4.5hrs when <80, 03hrs >80, no haemorrhage/infarct on CT. There is scoring system.
- Contraindications = BP consistent >180/105, stroke<3m/any ICH, surgery or bleed<3wks, (blood sugar really low/high, warfarin and INR>1.4), platelets <100. 15-2)% eligible.
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RFs for falls
- CV RFs - dehydration, blood loss, medication, cardiac arrhythmias, postural hypotension
- Confusion - delirium, dementia, alcohol and drugs, brain injury patholgoy
- Medications
- Postural instability
- Visual problems
- BPPV
Cause and RFs for pressure sores
- Cause = Pressure and/or shear forces over a bony prominence in the presence of a number of RFs (mostly immobility).
- RFs = Alzheimer’s, CVD, DM, COPD, Hip fracture, HF. DVT, limb paralysis, lower limb oedema, malignancy, Parkinson’s, RA, UTIs
Braden risk scale for pressure sores
•sensory perception, moisture, activity, mobility, nutrition, friction/shear.
Pressure sore - ulcer assessment
Cause, site, dimensions, age, exudate, signs inflamm, pain, wound appearance, surrounding skin, undermining/tracking (fistula), odour.
Management and complications of pressure sores
- Mx = Adequate pressure redistribution (pressur even), good nutrition, appropriate wound mx. Refer if extensive superficial or high grade. Repositioning, treat concurrent conditions, support usrfaces, pain relief, infection control.
- Complications – Cellulitis, joint infections (can damage cartilage and tissue), bone infections (osteomyeltitis- can reduce function of joints and limbs). Cancer (long term non helaing like marjolins ulcers -> SCC), sepsis.
Surgery and elderly - why is this more complicated
- In the frail – multicomponent intervention, frailty is significant risk factor for complications in elective + emergency surgical patients.
- Post op delirium – common + underdiagnosed + delays rehan
- Post-op pain – underappreciated in elderly (particularly those with cognitive disorders. Anesthetists should administer opioid sparing analgesia where possible.
- Elderly should be assumed to have capacity to make own decisions.
- Ass of anaethetists greta britian and Ireland aimed to give guidelines on peri-op care of elergy.
Types of incontinence
- Stress incontinence – urine leaks as pressure put on bladder like during exercise, cough, sneeze, laughing.
- Urge incontinence – sudden need to urinate and cant hold urine long enough to get to toilet. May be in DM, Alzheimer’s, Parkinson’s, MS, stroke
- Overflow incontinence – small amounts urine leak from bladder that’s always full. Eg , enlarged prostate blocking urethra. Diabetes AND spinal cord injuries can cause this.
- Functional incontinence – in those who have normal bladder control. Just have problem getting to toilet from arthritis or other disorders that mean you can move quick.
Invetsigations in incontinence and management
- Ix = physical exam, history, urine + blood samples, examine inside bladder with cystoscope, fill bladder with warm fluid and use cystoscope to check how much can hold before leaking, order bladder US to check fully emptying each void, keep diary.
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Mx =
- Bladder control training (Pelvic muscle exercise, urinary suppression-distraction and time voiding and extend).
- Medical – medications, vaginal estrogen cream (urge/stress), bulking agents (help close bladder opening), medical devices (catheter).
- Biofeedback (sensory to make aware of signals), electrical nerve stimulation, surgery.
- Behavior + lifestyle – loose weight, stop smoking, choose water, no to alcohol, prevent constipation.
DNA CPR - and how made
- DNACPR – Do not attempt CPR but can still have other forms active treatment
- On specific form, kept in medical records. Can have short period or no end date. Not legally binding unless advance decision to refuse treatment. If not have DNACPR then best interest decision but speak to important people to you or mental capacity advocate, MDT team.
- Might also have lasting power attorney document.
- Advanced decision/directive is essentially a living will, it is a signed legal dated document which involves patient detailing which treatments they wish to refuse. Must have been made when patient was “sound mind” and must be completed in presence of witness who must also sign and date document.
- Doctor decides in advance – even if don’t agree. If they think it would cause physical or psychological harm, but you should have chance to understand what it is and why they don’t think suitable. Individual basis, can ask for second opinions. Cant demand one if not deemed to be in best interest.
- Use when patients medical condition puts them at risk of having life threatening event or deterioration. When CPR would be deemed not successful due to condition (most successful when reversible cause)/ when they wish for one).
- In hospital – on nerve centre of not for resus (NFR) or yellow at front of notes. Medical decision with patient’s opinion but not legally binding till advanced directive. Cantdemand it but can refuse. Ignroe if DNACPR for cancer but go into cardiac arrest for different reason like procedure then can do CPR.
Adnvanced decision
- Advanced decision to refuse treatment, legally binding. To ensure individuals can refuse specific treatments that they do not want to have in the future
- Must be: valid (when they had capacity), must be applicable (specific to medical circumstances), made when over 18 + fully informed, not made under influence or people, must be written down, signed and witnessed.
- Can not refuse basic care etc or treatment for MHcondition if sectioned.
ADvanced statement
- Statement of wishes and care preferences. Allows individual to make general statements about wishes, beliefs, feeligns, values and how these influence their preferences.
- Not legally binding but must be taken into consideration when naking best interest decisions
- Religious, spiritual views, food preferences, infoabout daily routine where you would like to becared for, any people you would like to beconsulted when best interest decisions made (not same power as lasting power of attorney)
DNACPR convo
- Should be had at earliest opportunity
- Assess knowledge of patient, ’how much do they know’. If they don’t know much this may mean you will need to ‘break the bad news’.
- Offer to involve family or friends for emotional support
- ‘Warning shots’ or indicators of severity are often used to mentally prepare patients and families
- Should incorporate the patients wishes together with current medical opinions
- Should also involve possible of ceiling care
Symptoms in dying patients
- Recognizing dying: Cause of deterioration no longers responding to treatment or appropriate to treat.
- Expected: Changes in Obs, weakness + fatigue, decreased oral intake + swallow reflex, decreased blood perfusion, renal failure, incontinence/retention of urine, change in mental state (confusion, disorientation, delirium).
- Always ask the patient, family etc what they want. Transition to comfort care, stop Interventions + monitoring, treat symptoms + educate, oral and skin care. Be honest.
- Syndrome imminent death: 24hs-2wks. In early phase its bedbound, incontinent, decrease in ability and/or interest to eat or drink, cognitive changes. Then middle phase of tracheal congestion, further cognitive (slow to arouse), no oral intake. Late phase is comatose, temp instability, altered resp pattern, mottling + coole extremities, absence peripheral pulses.
End of life care - what to give for pain
- Pain: Conversion of usual daily dose of opiate analgesia to 24hour dose for use by syringe pump with 1/6 -> 1/10 of fsily dose andbreakthrough. Review every 24hours
- Morphine – first line for pain, monitor constipation and unwantedsedation
- Diamorphine, oxycodone, alfentayly (good for renal failure)
End of life care for breathlessness
•Breathlessness: May be from disease process, need therapeutic O2, morphine, midazolam
ENd of life care - for nausea and comtiing
•levomepropmazine, cyclizine, haloperidol, metoclopramide.
End of life care for restlessness and confusion
Haloperidol (not in parkinsoms), levomepromazine, midazolam .
End of life carefor repsirtory tract secretions
hyoscine hydrobromide, hyoscine butylbromide, glycopyrronium.
Common causes of falls
Usually an interaction to cause a fall. Weak muscles – affect strength + balance. From lack activity, arthritis…
- Poor balance – weak muscles, health conditions (parkinsons/stroke), S/Es, dizziness
- Dizziness – postural hypotension, inner ear probles, problems with HR/rhythm, dehydration
- Black outs, fainting etc – bradycardia, tachcyardia, Atrial fibrillation, foot problems – calluses, ingrown toenails, thicken nails, ulcers
- Mmeory loss, confusion, problem solving – cant judge risky situations
- Visio + hearing problems – spot hazard, depth perception for kerbs, cataracts, glaucoma
- Meds – psychotropics, BP lowering, sleeping tablets, anticonvulsants
- Alcohol – especially with some meds - can slow reactions
- Bladder and bowel conditions – rushing to toilet etc
Ix for falls
- Bedside = Vital signs (sepsis, bradycardia?), lying + standing BP (orthostatic hypotension), urine dipstick (infection, rhabdomyolysis), ECG (bradycardia, arrhythmias), Cogntivie screening (impairment), blood glucose (hypoglycaemia secondary to poor oral intake)
- Bloods = FBC (anaemia, infection), U&Es (dehydration, electrolyte abnormalities, rhabdomyolysis), LFTs (chronic alcohol use), bone profile (calcium abnormalities in malignancy or over supplementation)
- Imaging = CXR (pneumona), CT head (chronic or acute subdural/ stroke), ECHO (valvular heart disease (eg aortic stenosis))
- Specialist = Tilt table test, Epley maneuver (benign paroxysmal positional vertigo), Cardiac monitoring (eg 48hr tape- if no symptoms during monitoring episode in hospital).
Mx of falls
- Gait – physiotherapy
- Visual problems – Eye test. Ensure wears glasses
- Hearing difficulties – remove earwax, hearing assessment
- Meds review – reduce unnecessary medication
- Alcohol intake – Alcohol cessation advice, alcohol service referral
- Cognitive impairment – referral to psychiatric team
- Postural hypotension – review medication, improve hydration
- Continence – treat or rule out infections, continence assessment
- Footwear – Ensure good fitting footwear
- Environmental hazards – Turn on lights, take up rugs.
What is osteoporosis and rhw Risk factors
•Osteoporosis = Systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue (poor quality bone) with consequent increase in bone fragility and susceptibility to fracture
- RF = Age, sex, weight, previous fracture, parent fractured hip, current smoking, steroids, RA, alcohol 3 or more units/day, bone mineral density, secondary osteoporosis (eg T1DM, hyperthyroidism, hypogonadism, premature menopause (<45), chronic malnutrition, or malabsorption and chronic liver disease.
- Meds that worsen = SSRIs, antiepileptics, PPI, glitazones, long term heparin therapy, aromatase inhibitors eg, anastrozole
IX and assessing osteoporosis
- Ix - history and physical exam and blood cell count, sedimentation rate or CRP, serum calcium, albumin, creatinine, ALK, Liver trnasaminases, TFTs, DXA.
- Assessing = History, Exam, FRAX, DEXA
- DEXA (Dual energy Xray absorptiometry – measures Bone mineral density. Non invasive – measures at femoral neck and lumbar spine. Problematic if hip replacement as it would measure at titanium replacement.
>-1 = normal
-1 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Tx osteoporosis
- Tx = Address lifestyle factors + falls risk, optimize calcium and vitamin D status, minimize risk from other medical conditions. Medications…
- Anti-catabolic: Biphosphonate (reduce osteoclasts that eat bone to reduce bone loss) eg, alendronate (oral), risedronate (oral), ibandronate (IV), zolendronate (IV). Denosumab
- Anabolic – teriparatide (PTH type drug to increase deposition of bone)
- Try prevent with good balance and vitamin D
Delirium vs dementia
Different types dementia
