Geriatrics Flashcards
Delirium Dementia Parkinsonism Osteoporosis
classification of Parkinsonism
primary parkinsonism (neurodegeneration) vs secondary parkinsonism (eg. neuroleptics, encephalitis)
primary parkinsonism — parkinson’s disease vs atypical parkinsonism
eg. of atypical parkinsonism aka parinsons plus syndromes
PSP progressive supranuclear palsy
MSA multiple system atrophy
CBGD corticobasal ganglionic degeneration
lewy body dementia
presentation of parkinson’s disease
motor symptoms — asymmetrical + slow progression
akinesia/bradykinesia
rigidity — lead pipe or cogwheeling
gait disturbance, poor balance
resting tremor — pill rolling tremor
freezing of gait
stooped posture
non-motor symtpoms
neuropsychiatric — depression, apathy, anxiety, hallucinations, delusions, CI/dementia
sleep disturbance – REM behaviour disorder, restless legs
autonomic symptoms — bladder (urgency, nocturia, frequency), drenching sweat, postural hypotension, sexual dysfunction, impulse control disorder
GIT symptoms - CONSTIPATION
DDx lewy body dementia vs Parkinson’s disease
LBD
dementia before parkinsonism
REM sleep behaviour alot more prominent — usually predates parkinsonism
other features present:
fluctuating attention
visual hallucinations —- classic: lilliputian hallucinations
PD
dementia only in end stage disease (at least 10 yrs post-onset)
what scale is used in assessing Parkinson’s disease
unified parkinson’s disease rating scale
uses 4 domains
non-motor aspects of experiences of daily living
motor aspects of experiences of daily living
motor exam
motor complications
causes of sudden deterioration of Parkinson’s disease
constipation — reduced absorption of sinemet
illness
recent surgery or infection
stress
withdrawal
depression, anxiety
poor sleep
urinary retention
management of PD
MDT approach
physio —- exercise, maintain muscle mass
OT — walking aids, etc
Psychiatrist — due to neuropsychiatric complications
dietician — prevention of constipation
PD support group
PD nurse specialist — education re meds, timing, etc
conservative Tx
educate patient & fam
medical Tx
AVOID prochlorperazine, metoclopramide — antiemetic of choice = domperidone
prevent constipation — regular movicol
sinemet (carbidopa/levodopa)
if complex late stage = deep brain stimulation
what is delirium
acute + fluctuating change in mental status — characterised by inattention + disorganised thinking + altered level of consciousness
causes of delirium
DELIRIUUM
D: drugs
E: electrolyte & metabolic disturbances
L: lack of sleep/drugs (withdrawal)
I: infection, illness, recent surgery
R: reduced sensory input (no glasses, hearing aids)
I: intracranial (stroke, intracranial haemorrrhage, injury)
U: untreated pain
U: urinary retention, constipation
M: myocardial (MI, CHF) & pulmonary (hypoxia, hypercapnoea)
risk factors of delirium
precipitating factors — DELIRIUUM
predisposing factors
immobility
prev Hx delirium
increasing age
physical frailty
existing dementia or CI
visual or hearing impairment
polypharmacy
multiple co-morbidities
screening tool for delirium
4AT
criteria
Alertness — state name & adress
AMT4 — age, DOB, place, current year
Attention —- months of the year backwards from december
Acute change or fluctuating course
interpretation
0: delirium or severe CI unlikely
1-3: possible CI
4 or more: possible delirium +/- CI
others — general cognition screening
serial 7s — keep taking 7 away from 100
person, place, time, situation
types of delirium
hyperactive: heightened arousal + restless + agitation + hallucination
hypoactive: lethargy + lack of interest + reduced motor activity
mixed
Ix for delirium
Collateral Hx — nurses that usually care for him, family
physical exam — vitals, any pain, urinary retention, constipation
4AT
test for cognition — serial 7s, person place time situation
review drugs
bloods
capillary glucose
FBC
U&E
tox screen
septic screen
+/- ECG
+/- ABG
+/- CT Brain
management of delirium
approach patient in calm + collected manner to soothe patient
Tx underlying cause
patient centred environmental management
minimise pharmco
correct sensory issues
normalise sleep
regular reorientation & aids — calm + predictable routine, calendar clock, regular nurse supervision
educate caregivers + involve them
encourage early mobilisation
if risk to self or others + talking in a calm manner to soothe patient has failed = rapid tranquilisation protocol — haloperidol + lorazepam/promethazine
other options: quetiapine, risperidone
what is dementia
chronic + progressive brain disease —- characterised by impaired behaviour & intellect —- to the point that ADLs become impaired
diagnostic criteria of dementia
deficits in 2 or more cognitive domains (eg. memory, executive function, aphasia)
these cognitive deficits cause functional impairment in home or work life + represent a decline from prev function
ruled out alternative diagnosis – delirium, depression, psychiatric illnesses, potentially reversible causes of CI
what are ADLs
they stand for activities of daily living
this can be split into basic and instrumental ADLS
basic ADLs
dressing
eating
ambulation/transferring
toiletting
hygiene — bathing, grooming
instrumental ADLs
shopping
housekeeping
accounting
food prep
telephoning
transportation
what are some causes of reversible cognitive impairment
med S/E
excessive alcohol
psychiatric problems — eg. depression
hypothyroidism
B12 deficiency
normal P hydrocephalus
subdural haematoma
what is the presentation of normal pressure hydrocephalus
cognitive impairment + gait disturbance + urinary incontinence
what are the cognitive domains that can be involved in dementia
5 As
amnesia (memory loss)
aphasia (inability to speak or understand spoken language)
apraxia (loss of ability to coordinate learned movements despite intact motor function)
agnosia (inability to recognise what is seen despite intact sensory function
altered executive function
what are the most common causes of dementia in elderly
alzheimer’s disease 60%
vascular dementia 15-20%
mixed AD & VD 25%
diffuse LBD 15-25%
others
parkinson’s dementia
frontotemporal dementia
normal P hydrocephalus
what are key features of the different causes of dementia in elderly
alzheimers disease 60%
diagnosis of exclusion
usually >65 y/o
vascular dementia
step-wise progression over time
focal signs — depending on location of vascular lesion
vascular risk factors
diffuse LBD
fluctuating attention
visual hallucinations — lilliputian hallucinations
parkinsonism
REM sleep behaviour problems
what are the BPSD behavioural and psychological symptoms of dementia
they are symptoms that occur in 80% of patients with dementia
psychological symptoms: anxiety, depression, hallucinations, delusions
behavioural symptoms: aggression, screaming, restlessness, agitation, wandering, sexual disinhibition, hoarding, cursing
management of dementia
conservative Tx
create a routine in a familiar environment
carer support & advice – manage expectations (no cure)
avoid aggravators of dementia
advance care planning, power of attorney
recognition & management of BPSD behavioural & psychological symptoms of dementia
homecare package, ay centres
address safety issues — medicines, cooking, driving
medical Tx — to Tx cognitive symptoms + alter progression
acetylcholinesterase inhibitors — donepezil, rivastigmine, galantamine
ECG prior to starting — risk 1st degree HB
memantine (NMDA receptor antagonist)
better helps behavioural problems
DDx depression vs dementia
depression would have the SIG E CAPS symptoms
s: sleep
I: low interest
G: guilt/worthlessness
E: low energy
C: concentration
A: appetite, weight
P: psychomotor
S: suicidal
progression — depression = uneven progression over wks vs dementia = steady progression over months to yrs
insight —- depression = full insight (self complains of memory loss) vs dementia = lack insight (hides memory loss + unaware/minimises symptoms)
test performance — depression = presentation worse than performance vs dementia = presentation better than performance
aggravators of dementia
DEMENTIA
D: drugs
E: emotional illness
M: metabolic/endocrine disorders
E: eye/ear problems
N: nutrition
T: tumours or trauma
I: infections
A: alcohol
Ix for dementia
Hx & Exam
Hx — screen for BPSD, functional assessment, symptoms of alternative diagnosis (delirium, depression, reversible causes of CI), aggravators of dementia
Exam – neuro exam to r/o alternative diagnosis (stroke, parkinson;s)
screen for depression — geriatric depression scale
screen for delirium – 4AT
screen for cognition — MOCA, addenbrooke’s cognitive examination, MMSE
bloods — r/o alternative diagnosis
FBC
U&E
glucose
TFTs
B12
CT or MRI Brain — MRI»_space; CT
what is osteoporosis
it is low bone mineral density and micro-architectural deterioration — leading to bone fragility & susceptibility to fractures
it is defined by T score of less than - 2.5
severe osteoporosis: less than - 2.5 + fragility fracture
osteopaenia: between -1 and - 2.5
causes of osteoporosis
primary vs secondary
primary osteoporosis
age-related
post-menopausal
juvenile
idiopathic
secondary
genetic —- fam Hx, haemochormatosis, CF, idiopathic hypercalcuria
hypogonadal states — premature menopause, premature ovarian failure, etc
endocrine — adrenal insufficiency, DM, cushing’s syndrome
deficiency state — GI disorders — coeliac, malabsorption, IBD
meds — glucocorticoids
risk factors of osteoporosis
non-modifiable risk factors
age — older
sex — F > M
ethnicity — caucasian»_space; afro-carribean
hormonal factors
fam Hx
modifiable
smoking
alcohol — >3 units per dau
low BMI
lack of exercise
diet — malnutrition, low milk intake, vit D deficiency
what are fragility fractures + what do they imply
it is a fracture resulting from a mechanical force that would not ordinarily cause fractures
it is pathognomonic for osteoporosis regardless of the individual’s BMD
what are the most common fragility fractures
vertebral fracture (most common)
distal radius fracture aka colles fracture (2nd most common)
hip fracture (3rd most common)
Ix for fragility fracture
bloods
FBC
U&E
TFTs
CMP complete metabolic panel – incl Ca, Na, Cl, K, BUN, Cr, LFTs
biochemical markers of bone turnover
bone formation = P1NP, osteocalcin, bone-specific alk phos
bone resorption = CTx, NTx
FRAX fracture risk assessment tool
DEXA dual-energy xray absorptiometry scan
management of osteoporosis
conservative Tx
Ca replacement — calcichew 500mg BD
Vit D replacement — desunin 3200 units OD loading dose 6/52 — then maintenance 800 units OD
if CKD stage 3-5 + high phosphate = consult renal team
educate on falls prevention
advice on weight-bearing exercise
stop smoking
limit alcohol intake
medical Tx
bisphosphonates
MOA: inhibits calcification & bone resorption
wkly medication
take for 5 yrs then 2 yrs drug holiday then check DEXA again
S/E: osteonecrosis of jaw
C/I: eGFR <30, low Ca or Vit D, GERD PUD or oesophagitis
denosumab
subcutaneous injection every 6 months
impt to have normal Ca & Vit D levels prior to giving
what are the blue book guidelines for hip fractures
(7 total)
Admit to acute ortho ward within 4 hrs of presentation
Surgery within 48 hrs
minimise pressure ulcers
if fragility fracture = orthogeriatric support
antiresorptive meds
MDT assessment – prevent future falls
physio to assess within 24 hrs of presentation
what is a fall and what is a long lie
fall is an event that inadvertently resulting in a person coming to rest on the ground
a long lie is when the person falls and lies on the ground for more than 1 hr
risk factors for falls
environmental factors
obstacles on the floor
slippery surfaces — floor or shoes
lack of home modification
behavioural factors
lack of exercise
improper med usage — psychotropic drugs, sedative drugs
poor sleep hygiene
biological factors
vision impairment
gait disturbance
muscle weakness
orthostatic hypotension
postural instability
demographics
age
female gender
Hx of falls
what is syncope
total loss of consciousness — due to transient global cerebral hypoperfusion — characterised by rapid onset + short duration + spontaneous recovery
what are the types of transient loss of consciousness
traumatic TLOC
non-traumatic TLOC — syncope vs epileptic seizures vs psychogenic
syncope — reflex vs orthostatic vs cardiac syncope
what is orthostatic hypotension
drop in 20 mmHg SBP or 10 mmHg DBP when going from sitting to standing
causes of orthostatic hypotension
drug induced – vasodilators, diuretics, antidepressants, antihypertensives
vol depletion
primary autonomic failure — parkinson’s, LBD
secondary autonomic failure — DM, long inactivity, SC injury
definition of stroke & TIA
stroke:
traditional time-based definition: focal neurological deficit of acute onset + lasting >24 hrs — caused by acute ischaemia or haemorrhage to the brain
tissue-based definition: brain ischaemia or haemorrhage causing permanent tissue damage
TIA
traditional time-based definition focal neurological deficit —- acute onset + resolves within 24 hrs — caused by acute ischaemia or haemorrhage to the brain
tissue-based definition: brain ischaemia or haemorrhage causing only temporary tissue damage
causes of stroke
ischaemic 80%
large A atherosclerosis — internal carotid A»_space; common carotid
cardio-embolism
small A atherosclerosis
haemorrhagic 20%
what are the cerebrovascular risk factors for stroke
cvs
HTN
high cholesterol
IHD
afib
PVD peripheral vascular disease
arteritis
DM
smoking, alcohol, obesity
prev TIA/stroke
fam Hx TIA/stroke
drugs – cocaine
meds – OCP
Ix for stroke
Hx & exam
NIH (national institute of health) stroke scale
correlates well to size of infarct
bloods
FBC
U&E
serum glucose
LFTs
coag profile
ECG
non-contrast CT brain – ASPECTS score to detect early ischaemic changes
CT intracranial angiogram aortic arch to vertex
CT brain perfusion scan
management of ischaemic stroke
ABCDs
BP — ideally SBP 140-160
Tx if >220/120 or 180/105 + going for tPA
dont cause acute drops in SBP
if <4.5 hrs + no C/I = thrombolysis
if within 24 hrs = thrombectomy — eg. CEA carotid A endarterectomy
if neither = DAPT
thrombolysis = recombinant tissue plasminogen activator
(tenecteplase 0.25 mg/kg single IV bolus over 10s) — monitor patient for 15 mins
indication: within 4.5 hrs of symptom onset
S/E: 6% risk haemorrhage
C/I to thrombolysis
haemorrhagic stroke
symptom onset >4.5 hrs
known/suspected CNS lesion + high likelihood of haemorrhage after rt-PA
clinical presentation suggestive of SAH despite normal CT
bleeding disorder — Plt <100, INR >1.7
uncontrolled HTN — >180/105
major surgery within 14 days
minor surgery within 10 days
pregnant or postpartum within 10 days
dialysis — peritoneal or haemodialysis
NIHSS score >20 — ie v.bad infarct
if not then secondary prevention
DAPT — aspirin + clopidogrel loading dose 2 wks then aspirin alone
if due to afib = anticoagulation instead
statins
DM control
swallow screen within 4 hrs – keep NPO
fluids, BP
MDT management — physio, OT
complications of stroke
haemorrhagic transformation of ischaemic stroke – esp post tPA
brain oedema & malignant MCA
seizures
what is amaurosis fugax
blurring or loss of vision in whole or part of 1 eye — due to embolism or hypoperfusion to ophthalmic A or central retinal A
most commonly due to ipsilateral carotid stenosis
Ix for TIA transient ischaemic attack
Hx & Exam
bloods
FBC
U&E
HbA1c
lipids
CT +/- MRI Brain
Carotid doppler
ECHO
ECG + 24 hr holter
Tx of TIA
DAPT 3 wks then monotherapy
if afib = DOAC instead
CEA carotid endarterectomy within 2 wks
indication: >70% stenosis + symptomatic ipsilateral
no driving 1 wk
causes of haemorrhagic stroke
hypertension
CAA cerebral amyloid angiopathy
others
aneurysm
AV malformation
SOL/tumours
trauma
Tx of haemorrhagic stroke
stop antiplatelets & anticoagulants
reverse coagulopathy
warfarin = Vit K + PCC prothrombin complex concentrate
dabigatran = praxbind (idarucizumab)
xabans = andexanet alfa
heparin = protamine
careful BP reduction
neurosurgical
superficial or cerebellar bleed = evacuation
aneurysmal bleed = coiling
what is fragility
state of increased vulnerability to poor resolution of homeostasis after a stressor event — which increases risk of adverse outcomes (incl falls, delirium & disability)
Ix of fragility
Hx & Exam — markers of fragility = 3 or more of
weight loss
self-reported exhaustion
weakness
slow walking speed
decreased physical activity
rockwood clinical fraility scale
what is CGA comprehensive geriatric assessment
multidimensional interdisciplinary diagnostic process — focused on determining a frail older person’s medical, psychological & functional capability — in order to develop a coordinated & integrated plan for Tx & long term follow up
Ix for CGA
modified barthel index – for basic ADLs
modified rankin scale – for post-stroke
