Geriatrics Flashcards
What are the adverse effects of 5-HT3 antagonists?
Ondansetron
Palonosetron
Prolonged QT interval
What is the STOPP tool for?
Identifies medications where the risk outweighs the therapeutic benefits in certain conditions
Particularly in polypharmacy
What is the START tool for?
To identify medications that may provide additional benefits
What is the definition of multimorbidity?
The presence of two or more long-term health conditions, including: Defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
What are the RFs for multimorbidity?
Increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity
How should frailty be assessed?
Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire
What are the features of lewy body dementia?
Main three things: fluctuating cognitive impairment, Parkinsonism and visual hallucinations
Progressive cognitive impairment- typically occurs before parkinsonism, but usually both features occur within a year of each other. This is in contrast to Parkinson’s disease, where the motor symptoms typically present at least one year before cognitive symptoms
Cognition may be fluctuating, in contrast to other forms of dementia
In contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
Parkinsonism
Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
How is lewy body dementia diagnosed?
Usually clinical
Single-photon emission computed tomography (SPECT) (known as a DaTscan)
What is the management of lewy body dementia?
Both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s
Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent
What score is used to assess a patient’s risk of pressure sores?
Waterlow score
What are the RFs for pressure sores?
Malnourishment
Incontinence
Lack of mobility
Pain (leads to a reduction in mobility)
What grades can pressure sores be?
Grade 1- erythema
Grade 2- partial thickness skin loss
Grade 3- full thickness skin loss
Grade 4- extensive desruction, damage to muscle and bone
What is the management of pressure sores?
Moist wound environment
Antibiotics administered on clinical basis
Maybe surgical debridement
What is acute delusional state?
Delirium
What are the predisposing factors for delirium?
Age > 65 years
Background of dementia
Significant injury e.g. hip fracture
Frailty or multimorbidity
Polypharmacy
What are some precipitating events for delirium?
Infection: particularly urinary tract infections
Metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
Change of environment
Any significant cardiovascular, respiratory, neurological or endocrine condition
Severe pain
Alcohol withdrawal
Constipation
What are the features of delirium (wide variety of presentations)?
Memory disturbances (loss of short term > long term)
May be very agitated or withdrawn
Disorientation
Mood change
Visual hallucinations
Disturbed sleep cycle
Poor attention
What is the management of delirium?
Treat underlying cause
Modification of the environment
Haloperidol as the first line sedative
Management challenging in Parkinson’s patients as antipsychotics can worsen Parkinsonism symptoms- reduction of Parkinson’s medication or clozapine
Causes of delirium help
P - Pain
I - Infection
N - Nutrition
C - Constipation/urinary retention
H - Hydration
M - Medication/Metabolic
E - Environmental stressors
Factors favouring delirium over dementia?
Acute onset
Impairment of consciousness
Fluctuation of symptoms: worse at night, periods of normality
Abnormal perception (e.g. illusions and hallucinations)
Agitation, fear
Delusions
Parkinson’s and delirium which drug is contraindicated?
Haloperidol
When should you prescribe antibiotics for pressure ulcers?
If there is evidence of infection
NICE suggest that indications for antibiotic use are as follows:
Clinical evidence of systemic sepsis
Spreading cellulitis
Underlying osteomyelitis.
Can you prescribe a tricyclic antidepressant in dementia?
No, makes it worse
Assessment tools for dementia in non specialist setting?
10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT)
Assessment tools for dementia in the specialist setting?
Abbreviated mental test score (AMTS)
General practitioner assessment of cognition (GPCOG)
The mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia
What is the management of dementia?
In primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’)
In secondary care, neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management
What does a middle aged man with insidious onset dementia and personality changes suggest?
Frontotemporal dementia (Pick’s disease)
What age range is frontotemporal dementia most common?
Under 65
What are the three types of frontotemporal lobar degeneration (FTLD)
Frontotemporal dementia (Pick’s disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
What are the common feaeetures of FTLDs?
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
What are the features of Pick’s disease?
Characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours
Do not sure AChE inhibitors
What does stepwise declines in function suggest?
Vascular dementia
What part of the brain is affected in Alzheimer’s disease?
Cortex and hippocampus
What are the risk factors for Alzheimer’s dementia?
Increasing age
Family history of Alzheimer’s disease
Apoprotein E allele E4 - encodes a cholesterol transport protein
Caucasian ethnicity
Down’s syndrome
What are the pathological changes in Alzheimer’s disease?
Macroscopic:
widespread cerebral atrophy, particularly involving the cortex and hippocampus
Microscopic:
cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Biochemical
there is a deficit of acetylcholine from damage to an ascending forebrain projection
How to differentiate between lewy body dementia and Parkinson’s dementia?
Overlapping features such as tremors, rigidity, postural instability, fluctuating cognition, and hallucinations
Time of onset of dementia compared to motor symptoms
PPD diagnosed if Parkinson’s diagnosis (motor symptoms) for at least 1 year before the cognitive symptoms
What are the acetylcholinesterase inhibitors?
Donepezil, Rivastigmine, Galantamine
What is the management of Alzheimer’s disease?
Offer activites and mental stimulation
The three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
Memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used in the following situation reserved for patients with
moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
monotherapy in severe Alzheimer’s
Pharmacological management of Alzheimer’s?
1st- acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
2nd- Memantine
No antidepressants
Antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
Donepezil contraindications?
Is relatively contraindicated in patients with bradycardia
Adverse effects include insomnia
What class of medication is associated with significant mortality rates in dementia patients?
Antipsychotics
What investigations are in a confusion screen?
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
Why avoid neuroleptics (antipsychotics) in Lewy body dementia?
May cause irreversible Parkinsonism
Drugs to avoid in Lewy body dementia?
Avoid HARM drugs
H- haloperidol
A- antipsychotics (in general)
R- pRochlorperazine
M- metoclopramide
What type of drug is memantine?
NMDA antagonist
What type of drug is donepezil?
Acetylcholinesterase inhibitors
Risk factors for falling?
Previous falls
Lower limb muscle weakness
Vision problems
Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
Polypharmacy (4+ medications)
Incontinence
>65
Have a fear of falling
Depression
Postural hypotension
Arthritis in lower limbs
Psychoactive drugs
Cognitive impairment
What is the investigation for vascular dementia?
MRI head
Distinguish between dementia and delirium?
Factors favouring delirium over dementia:
Acute onset
Impairment of consciousness
Fluctuation of symptoms: worse at night, periods of normality
Abnormal perception (e.g. illusions and hallucinations)
Agitation, fear
Delusions
MS: Tools for diagnosis of delirium?
CAM
4AT
DSM-5
Delirium subtypes?
Hyperactive
Hypoactive
Mixed
Who involved at MDT?
Transfer of care
Physio
Occupational health
Speech and language therapy
Dieticians
Pharmacists
FDRT
After fall and laying on floor?
Rhabdomyolysis
Features of rhabdomyolysis?
AKI with disproportionatley raised creatine
Elevated CK
Myoglobinuria- dark or reddish brown colour urine
IV fluids
Urine alkalisation
Osteoporosis RFs?
Female
Age
Corticosteroid use
Smoking
Alcohol
Low BMI
FH
Screening tool for osteoporosis?
FRAX- 10 year risk of developing a fracture
DEXA scan to assess mineral bone density
T score of less that -2.5 treatment recommended
Osteoporosis management?
Vit D and calcium to all women
Bisphosphonate- Alendronate
How to assess people at risk of falls?
Timed up and go test
Turn 180 test
