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Geriatrics Flashcards

Delirium Dementia Parkinsonism Osteoporosis

1
Q

classification of Parkinsonism

A

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

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2
Q

presentation of parkinson’s disease

A

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

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3
Q

DDx lewy body dementia vs Parkinson’s disease

A

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)

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4
Q

what scale is used in assessing Parkinson’s disease

A

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

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5
Q

causes of sudden deterioration of Parkinson’s disease

A

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

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6
Q

management of PD

A

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

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7
Q

what is delirium

A

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

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8
Q

causes of delirium

A

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)

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9
Q

risk factors of delirium

A

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

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10
Q

screening tool for delirium

A

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

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11
Q

types of delirium

A

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

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12
Q

Ix for delirium

A

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

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13
Q

management of delirium

A

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

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14
Q

what is dementia

A

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

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15
Q

diagnostic criteria of dementia

A

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

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16
Q

what are ADLs

A

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

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17
Q

what are some causes of reversible cognitive impairment

A

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

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18
Q

what is the presentation of normal pressure hydrocephalus

A

cognitive impairment + gait disturbance + urinary incontinence

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19
Q

what are the cognitive domains that can be involved in dementia

A

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

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20
Q

what are the most common causes of dementia in elderly

A

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

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21
Q

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

A

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

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22
Q

what are the BPSD behavioural and psychological symptoms of dementia

A

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

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23
Q

management of dementia

A

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

24
Q

DDx depression vs dementia

A

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

25
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
26
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 >> CT
27
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
28
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
29
risk factors of osteoporosis
non-modifiable risk factors age --- older sex --- F > M ethnicity --- caucasian >> 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
30
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
31
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)
32
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
33
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
34
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
35
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
36
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
37
what is syncope
total loss of consciousness --- due to transient global cerebral hypoperfusion --- characterised by rapid onset + short duration + spontaneous recovery
38
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
39
what is orthostatic hypotension
drop in 20 mmHg SBP or 10 mmHg DBP when going from sitting to standing
40
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
41
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
42
causes of stroke
ischaemic 80% large A atherosclerosis --- internal carotid A >> common carotid cardio-embolism small A atherosclerosis haemorrhagic 20%
43
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
44
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
45
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
46
complications of stroke
haemorrhagic transformation of ischaemic stroke -- esp post tPA brain oedema & malignant MCA seizures
47
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
48
Ix for TIA transient ischaemic attack
Hx & Exam bloods FBC U&E HbA1c lipids CT +/- MRI Brain Carotid doppler ECHO ECG + 24 hr holter
49
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
50
causes of haemorrhagic stroke
hypertension CAA cerebral amyloid angiopathy others aneurysm AV malformation SOL/tumours trauma
51
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
52
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)
53
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
54
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
55
Ix for CGA
modified barthel index -- for basic ADLs modified rankin scale -- for post-stroke

Medicine (18 decks)

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