Geriatrics

Question 1

classification of Parkinsonism

Answer 1

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

Question 2

presentation of parkinson’s disease

Answer 2

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

Question 3

DDx lewy body dementia vs Parkinson’s disease

Answer 3

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)

Question 4

what scale is used in assessing Parkinson’s disease

Answer 4

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

Question 5

causes of sudden deterioration of Parkinson’s disease

Answer 5

constipation — reduced absorption of sinemet
illness
recent surgery or infection
stress
withdrawal
depression, anxiety
poor sleep
urinary retention

Question 6

management of PD

Answer 6

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

Question 7

what is delirium

Answer 7

acute + fluctuating change in mental status — characterised by inattention + disorganised thinking + altered level of consciousness

Question 8

causes of delirium

Answer 8

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)

Question 9

risk factors of delirium

Answer 9

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

Question 10

screening tool for delirium

Answer 10

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

Question 11

types of delirium

Answer 11

hyperactive: heightened arousal + restless + agitation + hallucination
hypoactive: lethargy + lack of interest + reduced motor activity
mixed

Question 12

Ix for delirium

Answer 12

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

Question 13

management of delirium

Answer 13

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

Question 14

what is dementia

Answer 14

chronic + progressive brain disease —- characterised by impaired behaviour & intellect —- to the point that ADLs become impaired

Question 15

diagnostic criteria of dementia

Answer 15

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

Question 16

what are ADLs

Answer 16

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

Question 17

what are some causes of reversible cognitive impairment

Answer 17

med S/E
excessive alcohol
psychiatric problems — eg. depression
hypothyroidism
B12 deficiency
normal P hydrocephalus
subdural haematoma

Question 18

what is the presentation of normal pressure hydrocephalus

Answer 18

cognitive impairment + gait disturbance + urinary incontinence

Question 19

what are the cognitive domains that can be involved in dementia

Answer 19

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

Question 20

what are the most common causes of dementia in elderly

Answer 20

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

Question 21

what are key features of the different causes of dementia in elderly

Answer 21

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

Question 22

what are the BPSD behavioural and psychological symptoms of dementia

Answer 22

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

Question 23

management of dementia

Answer 23

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

Question 24

DDx depression vs dementia

Answer 24

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

Question 25

aggravators of dementia

Answer 25

DEMENTIA
D: drugs
E: emotional illness
M: metabolic/endocrine disorders
E: eye/ear problems
N: nutrition
T: tumours or trauma
I: infections
A: alcohol

Question 26

Ix for dementia

Answer 26

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&raquo_space; CT

Question 27

what is osteoporosis

Answer 27

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

Question 28

causes of osteoporosis

Answer 28

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

Question 29

risk factors of osteoporosis

Answer 29

non-modifiable risk factors
age — older
sex — F > M
ethnicity — caucasian&raquo_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

Question 30

what are fragility fractures + what do they imply

Answer 30

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

Question 31

what are the most common fragility fractures

Answer 31

vertebral fracture (most common)
distal radius fracture aka colles fracture (2nd most common)
hip fracture (3rd most common)

Question 32

Ix for fragility fracture

Answer 32

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

Question 33

management of osteoporosis

Answer 33

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

Question 34

what are the blue book guidelines for hip fractures

Answer 34

(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

Question 35

what is a fall and what is a long lie

Answer 35

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

Question 36

risk factors for falls

Answer 36

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

Question 37

what is syncope

Answer 37

total loss of consciousness — due to transient global cerebral hypoperfusion — characterised by rapid onset + short duration + spontaneous recovery

Question 38

what are the types of transient loss of consciousness

Answer 38

traumatic TLOC

non-traumatic TLOC — syncope vs epileptic seizures vs psychogenic

syncope — reflex vs orthostatic vs cardiac syncope

Question 39

what is orthostatic hypotension

Answer 39

drop in 20 mmHg SBP or 10 mmHg DBP when going from sitting to standing

Question 40

causes of orthostatic hypotension

Answer 40

drug induced – vasodilators, diuretics, antidepressants, antihypertensives
vol depletion
primary autonomic failure — parkinson’s, LBD
secondary autonomic failure — DM, long inactivity, SC injury

Question 41

definition of stroke & TIA

Answer 41

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

Question 42

causes of stroke

Answer 42

ischaemic 80%
large A atherosclerosis — internal carotid A&raquo_space; common carotid
cardio-embolism
small A atherosclerosis

haemorrhagic 20%

Question 43

what are the cerebrovascular risk factors for stroke

Answer 43

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

Question 44

Ix for stroke

Answer 44

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

Question 45

management of ischaemic stroke

Answer 45

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

Question 46

complications of stroke

Answer 46

haemorrhagic transformation of ischaemic stroke – esp post tPA

brain oedema & malignant MCA

seizures

Question 47

what is amaurosis fugax

Answer 47

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

Question 48

Ix for TIA transient ischaemic attack

Answer 48

Hx & Exam

bloods
FBC
U&E
HbA1c
lipids

CT +/- MRI Brain
Carotid doppler
ECHO
ECG + 24 hr holter

Question 49

Tx of TIA

Answer 49

DAPT 3 wks then monotherapy
if afib = DOAC instead

CEA carotid endarterectomy within 2 wks
indication: >70% stenosis + symptomatic ipsilateral

no driving 1 wk

Question 50

causes of haemorrhagic stroke

Answer 50

hypertension
CAA cerebral amyloid angiopathy

others
aneurysm
AV malformation
SOL/tumours
trauma

Question 51

Tx of haemorrhagic stroke

Answer 51

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

Question 52

what is fragility

Answer 52

state of increased vulnerability to poor resolution of homeostasis after a stressor event — which increases risk of adverse outcomes (incl falls, delirium & disability)

Question 53

Ix of fragility

Answer 53

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

Question 54

what is CGA comprehensive geriatric assessment

Answer 54

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

Question 55

Ix for CGA

Answer 55

modified barthel index – for basic ADLs
modified rankin scale – for post-stroke