Geriatrics

Question 1

Polypharmacy definition, prevalence, management

Answer 1

> 5 meds
36% of >70yo
No mortality in RCTs but has been shown to do so in some small trials - personalised seems to carry benefit

Question 2

Common drugs that pose risk in older patients (6)

Answer 2

1. NSAIDs - bleed, AKI, HTN
2. Benzo - fall
3. Anticholinergic - retention, cog impairment
4. TCA - hypotension, sedation
5. SU - hypoglycaemia
6. Prazosin - hypotension, dry mouth, urinary issues

Question 3

Delirium definition and prevalence in gen med, ED, ICU

Answer 3

disturbance in attention and awareness that occurs acutely and fluctuates
with an additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception)

Gen med 1/4 (same for stroke, post-cabg)
ED 15%
ICU 50-70%
Pall care 59-88%

Question 4

Risk factors (6) and causes for delirium

Answer 4

Risk:
1. EtOH abuse 5.7x
2. Age 4x
3. Functional disability 4x
4. Malnutrition 4x
5. Dementia 3x
6. Visual and hearing impairment 3x

Causes:
Acute illness/ infection
Medications
Electrolytes
IDC

Question 5

Delirium outcomes (5)

Answer 5

36% delirium at discharge

1. Mortality 2-4x (in-hospital and 39 vs 23% @ 2yrs)
2. Length of stay 2x
3. Cognitive decline - 10x risk of dementia, 3x worse rate
4. Complications 3x
5. Nursing home 3x

Question 6

Delirium prevention, detection, treatment

Answer 6

Prevention - multicomponent interventions OR 0.47
Detection - 4AT (88% pooled sensitivity & specificity)
EEG - 100% sensitivity (less so with dementia)

Melatonin 49% risk reduction
Survorexant (orexin antagonist - inhibits arousal and promotes sleep) 70% reduction in ICU
(50% when combined with melatonin)

other drugs do not reduce severity, duration, symptoms, length of stay, mortality

Question 7

Dementia prevelance

Answer 7

4th leading cause of death
Doubles every 5 years past 60yo
Higher in Aboriginal Australians

Question 8

Alzheimer’s diseases pathologies

Answer 8

1. Plaques and tangles
2. Microvascular lesions
3. Atrophy
4. Hippocampal sclerosis
5. Cortical Lewy bodies

Question 9

Causes of dementia in order of prevalence

Answer 9

1. Alzheimer
2. Vascular (up to 75% will have some evidence of it)
3. Limbic predominant age-related TDP-43 encephalopathy neuropathological change (LATE-NC)
4. Levy body (alpha synucleinopathy)

Question 10

Frontotemporal dementia types

Answer 10

1. Behaviour = personality - apathy + inappropriate; cognitive - executive dysfunction + memory
2. Primary progressive aphasia = impairment in language: logopenic, semantic, agrammatic
3. Motoric = impairment in attention, executive functioning and visuospatial&raquo_space; may accompany PSP, corticobasal degeneration, MND

Question 11

cholinesterase inhibitors

Answer 11

symptomatic (no disease modifications)
some evidence of improvement in carer rated quality of life

not indicated in mild cognitive impairment

Question 12

Memantine

Answer 12

NMDA receptor antagonist

Small benefit on cognitive function and functional decline
Mod-severe Alzheimer

Question 13

Aducanumab

Answer 13

anti amyloid beta ab
Controversial - surrogate improvement in plaque, NO improvement clinically and serious cerebral oedema and hemorrhage

Question 14

Dementia symptom management

Answer 14

Citalopram (SSRI) for agitation
Severe symptoms - offer risperidone or olanzapine

Question 15

Dementia prevention

Answer 15

Cardiovascular health
Exercise
Avoid EtOH and smoking
Reduce depression + maintain social contact
Education
Treat hearing impairment

Question 16

Synucleinopathies and tauopathies - 3 each

Answer 16

Synucleinopathies
- Parkinson
- Lewy body Dementia
- MSA

Tauopathies
- Alzheimer
- PSP
- Corticobasal degeneration