Geriatrics

Question 1

What is the classification of hyponatraemia

Answer 1

<135mmol/L

Question 2

What is the classification of severe hyponatraemia

Answer 2

<125mmol/l

Question 3

What are the three types of hyponatraemia?

Answer 3

hypovolaemic
euvolaemic
hypervolaemia

Question 4

List some causes of hypervolaemic hyponatraemia

Answer 4

-Heart failure
- liver cirrhosis
- kidney failure
-nephrotic syndrome

Question 5

List some causes of hypovolaemic hyponatraemia

Answer 5

-GI loss: diarrhoea and vomiting
-renal loss: salt wasting nephropathies, diuretics
-third space losses- e.g. pancreatitis, sepsis.
- Skin loss: sweating, burns
-primary adrenal insufficiency
-cerebral salt wasting syndrome

Question 6

List some causes of euvolaemic hyponatraemia

Answer 6

-SIADH
-high fluid intake
-medications

Question 7

Presentation of hyponatraemia

Answer 7

lethargy, headaches, irritability, nausea and vomiting, confusion, seizures, coma, loss of consciousness, signs of causes (e.g. if HF- SOB)

Question 8

How is hyponatraemia treated

Answer 8

• if acute with neurological signs: replace sodium with hypertonic saline
• if chronic: treat cause
  hypervolaemia and euvolaemic- fluid restriction or ADH receptor antagonist (tolvaptan)
  hypovolaemic- IV fluids.

Question 9

Complication of hyponatraemia

Answer 9

cerebral oedema

Question 10

At what rate should sodium be replaced and if too quick what could be caused?

Answer 10

• no quicker than 8mmol/L/day
• cerebral pontine myelinisation (osmotic demyelination syndrome)

Question 11

What is delirium?

Answer 11

An acute fluctuating change in mental status with inattention, disorganised thinking and altered levels of consciousness.

Question 12

List some predisposing factors for delirium

Answer 12

old age
dementia
visual or hearing impairment
immobility or functional impairment
past history of delirium
dehydration
polypharmacy
co-existing medical condition
physical frailty

Question 13

List some precipitating insults that may cause delirium

Answer 13

Medications (alcohol, sedatives, narcotics)
Primary neurological injury- e.g. stroke, meningitis
acute illness- infection (pneumonia, UTI), hypoxia, shock, dehydration, constipation
metabolic abnormalities- hypo/hyperglycaemia, electrolyte abnormalities,
surgery
iatrogenic events- e.g. catheters, being in intensive care
pain
prolonged sleep deprivation
drug withdrawal- e.g. alcohol

Question 14

What are the three types of delirium?

Answer 14

hyperactive, hypoactive and mixed

Question 15

How would hyperactive delirium present?

Answer 15

patient has heightened arousal with restlessness, agitation, hallucinations and inappropriate behaviour

Question 16

How would hypoactive delirium present?

Answer 16

patient may be lethargic, have reduced motor activity, incoherent speech and lack of interest

Question 17

Features of delirium in the DSM classification

Answer 17

1. A disturbance in attention with reduced ability to focus, sustain or shift attention.
2. A change in cognition or the development of a perceptual disturbance not better accounted for by pre-existing or evolving dementia
3. The disturbance developed over a short period of time, represents an acute change from baseline and tends to fluctuate through the day
4. There is evidence from the history, physical exam, or lab findings that the disturbance is caused by consequences of a general medical condition, substance intoxication, or substance withdrawal.

Question 18

Key differentials for delirium

Answer 18

Depression
mental illness (psychosis)
dementia
thyroid disease

Question 19

How can delirium be prevented on a ward?

Answer 19

• care by a familiar team
  -avoid moving around the ward
• appropriate lighting
• orientation: a clock/ calender
• cognitively stimulating activities
  -regular visits with family
  -address risk factors- hydration, hypoxia, infection, immobility, pain, medication

Question 20

What medication may be considered if severe distress caused by delirium

Answer 20

haloperidol.

Question 21

what is benign paroxysmal positional vertigo

Answer 21

a common cause of recurrent vertigo triggered by head movements

Question 22

What is the pathophysiology of benign paroxysmal positional vertigo

Answer 22

otoconia- loose debris of calcium carbonate within the semilunar canals of the inner ear (mainly in the posterior semicircular canal)
The attacks are triggered by head movements which cause movement of the otoconia, abnormal motion of the endolymph and a feeling of vertigo

Question 23

Presentation of BPPV

Answer 23

short episodes of vertigo lasting typically less than 1 minute
Episodes are triggered by head movements such as rolling over in bed
They may cause nausea and vomiting
No change in hearing or tinnitus

Question 24

How is BPPV diagnosed?

Answer 24

the Dix-Hallpike manoeuvre

Question 25

Describe the Dix-Hallpike manoeuvre

Answer 25

Patient sits with head turned 45 degrees to the side
The patient is lowered rapidly to laying with their head still turned to 45 degrees to a point where their head hangs off the edge of the couch extended to 20-30 degrees
The patient is held in this position for 30-60 seconds and their eyes are watched for nystagmus (BPPV causes rotational nystagmus towards the affected ear and feelings of vertigo)

Question 26

How is BPPV treated?

Answer 26

the Epley manoeuvre and Brandt- Daroff exercises

Question 27

Describe the Epley manoeuvre

Answer 27

Begins the same as the Dix-Hallpike manoeuvre (patient starts sitting with head 45 degrees to side and is then lowered to laying rapidly)
The patients head is then turned 90 degrees past central to face the other side
The patient is then turned onto their side to that their head rotates another 90 degrees
The patient then sits up sideways with legs over the side of the couch
The head is then placed centrally with the chin flexed towards the chest

Question 28

What are Brandt-Daroff exercises

Answer 28

exercises that can be performed by the patient at home
The patient sits on the end of the bed and lies sideways then moves from side to the other side while rotating the head slightly to face the ceiling

Question 29

What is the definition of polypharmacy

Answer 29

taking over 5 different medications

Question 30

What two types of polypharmacy are there?

Answer 30

appropriate polypharmacy- prescribing for complex medical conditions where the medicines have been optimised and prescribed according to best evidence

problematic polypharmacy - prescribing multiple medications inappropriately

Question 31

SE of beta blockers

Answer 31

cool peripheries, bradycardia

Question 32

can you give metformin in low eGFR

Answer 32

no

Question 33

metabolic abnormality of ACEi

Answer 33

hyperkalaemia

Question 34

SE of statins

Answer 34

muscle cramps
confusion
LFT changes