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Phase 3a > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What are the adverse effects of 5-HT3 antagonists?

A

Ondansetron
Palonosetron

Prolonged QT interval

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2
Q

What is the STOPP tool for?

A

Identifies medications where the risk outweighs the therapeutic benefits in certain conditions

Particularly in polypharmacy

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3
Q

What is the START tool for?

A

To identify medications that may provide additional benefits

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4
Q

What is the definition of multimorbidity?

A

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

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5
Q

What are the RFs for multimorbidity?

A

Increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity

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6
Q

How should frailty be assessed?

A

Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire

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7
Q

What are the features of lewy body dementia?

A

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)

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8
Q

How is lewy body dementia diagnosed?

A

Usually clinical

Single-photon emission computed tomography (SPECT) (known as a DaTscan)

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9
Q

What is the management of lewy body dementia?

A

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

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10
Q

What score is used to assess a patient’s risk of pressure sores?

A

Waterlow score

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11
Q

What are the RFs for pressure sores?

A

Malnourishment

Incontinence

Lack of mobility

Pain (leads to a reduction in mobility)

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12
Q

What grades can pressure sores be?

A

Grade 1- erythema

Grade 2- partial thickness skin loss

Grade 3- full thickness skin loss

Grade 4- extensive desruction, damage to muscle and bone

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13
Q

What is the management of pressure sores?

A

Moist wound environment

Antibiotics administered on clinical basis

Maybe surgical debridement

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14
Q

What is acute delusional state?

A

Delirium

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15
Q

What are the predisposing factors for delirium?

A

Age > 65 years

Background of dementia

Significant injury e.g. hip fracture

Frailty or multimorbidity

Polypharmacy

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16
Q

What are some precipitating events for delirium?

A

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

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17
Q

What are the features of delirium (wide variety of presentations)?

A

Memory disturbances (loss of short term > long term)

May be very agitated or withdrawn

Disorientation

Mood change

Visual hallucinations

Disturbed sleep cycle

Poor attention

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18
Q

What is the management of delirium?

A

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

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19
Q

Causes of delirium help

A

P - Pain
I - Infection
N - Nutrition
C - Constipation/urinary retention
H - Hydration
M - Medication/Metabolic
E - Environmental stressors

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20
Q

Factors favouring delirium over dementia?

A

Acute onset

Impairment of consciousness

Fluctuation of symptoms: worse at night, periods of normality

Abnormal perception (e.g. illusions and hallucinations)

Agitation, fear

Delusions

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21
Q

Parkinson’s and delirium which drug is contraindicated?

A

Haloperidol

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22
Q

When should you prescribe antibiotics for pressure ulcers?

A

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.

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23
Q

Can you prescribe a tricyclic antidepressant in dementia?

A

No, makes it worse

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24
Q

Assessment tools for dementia in non specialist setting?

A

10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT)

25
Q

Assessment tools for dementia in the specialist setting?

A

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

26
Q

What is the management of dementia?

A

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

27
Q

What does a middle aged man with insidious onset dementia and personality changes suggest?

A

Frontotemporal dementia (Pick’s disease)

28
Q

What age range is frontotemporal dementia most common?

A

Under 65

29
Q

What are the three types of frontotemporal lobar degeneration (FTLD)

A

Frontotemporal dementia (Pick’s disease)

Progressive non fluent aphasia (chronic progressive aphasia, CPA)

Semantic dementia

30
Q

What are the common feaeetures of FTLDs?

A

Onset before 65

Insidious onset

Relatively preserved memory and visuospatial skills

Personality change and social conduct problems

31
Q

What are the features of Pick’s disease?

A

Characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours

Do not sure AChE inhibitors

32
Q

What does stepwise declines in function suggest?

A

Vascular dementia

33
Q

What part of the brain is affected in Alzheimer’s disease?

A

Cortex and hippocampus

34
Q

What are the risk factors for Alzheimer’s dementia?

A

Increasing age

Family history of Alzheimer’s disease

Apoprotein E allele E4 - encodes a cholesterol transport protein

Caucasian ethnicity

Down’s syndrome

35
Q

What are the pathological changes in Alzheimer’s disease?

A

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

36
Q

How to differentiate between lewy body dementia and Parkinson’s dementia?

A

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

37
Q

What are the acetylcholinesterase inhibitors?

A

Donepezil, Rivastigmine, Galantamine

38
Q

What is the management of Alzheimer’s disease?

A

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

39
Q

Pharmacological management of Alzheimer’s?

A

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

40
Q

Donepezil contraindications?

A

Is relatively contraindicated in patients with bradycardia

Adverse effects include insomnia

41
Q

What class of medication is associated with significant mortality rates in dementia patients?

A

Antipsychotics

42
Q

What investigations are in a confusion screen?

A

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

43
Q

Why avoid neuroleptics (antipsychotics) in Lewy body dementia?

A

May cause irreversible Parkinsonism

44
Q

Drugs to avoid in Lewy body dementia?

A

Avoid HARM drugs
H- haloperidol
A- antipsychotics (in general)
R- pRochlorperazine
M- metoclopramide

45
Q

What type of drug is memantine?

A

NMDA antagonist

46
Q

What type of drug is donepezil?

A

Acetylcholinesterase inhibitors

47
Q

Risk factors for falling?

A

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

48
Q

What is the investigation for vascular dementia?

A

MRI head

49
Q

Distinguish between dementia and delirium?

A

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

50
Q

MS: Tools for diagnosis of delirium?

A

CAM

4AT

DSM-5

51
Q

Delirium subtypes?

A

Hyperactive
Hypoactive
Mixed

52
Q

Who involved at MDT?

A

Transfer of care

Physio

Occupational health

Speech and language therapy

Dieticians

Pharmacists

FDRT

53
Q

After fall and laying on floor?

A

Rhabdomyolysis

54
Q

Features of rhabdomyolysis?

A

AKI with disproportionatley raised creatine

Elevated CK

Myoglobinuria- dark or reddish brown colour urine

IV fluids
Urine alkalisation

55
Q

Osteoporosis RFs?

A

Female
Age

Corticosteroid use
Smoking
Alcohol
Low BMI
FH

56
Q

Screening tool for osteoporosis?

A

FRAX- 10 year risk of developing a fracture

DEXA scan to assess mineral bone density

T score of less that -2.5 treatment recommended

57
Q

Osteoporosis management?

A

Vit D and calcium to all women

Bisphosphonate- Alendronate

58
Q

How to assess people at risk of falls?

A

Timed up and go test

Turn 180 test

Phase 3a (17 decks)

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