Geriatrics Flashcards
What is delirium?
an acute and fluctuating state of confusion, usually precipitated by illness, injury or drug toxicity or withdrawal
Types of delirium?
Hyperactive
Hypoactive
Mixed
4 Key Characteristics of delirium?
Fluctuating Pattern
Inattention
Acute change in cognition
Temporary in relation to illness
Causes of Delirium?
Pain
Infection
Constipation/Urinary Retention
Hydration/Nutrition
Medications
Electrolyte Disturbances/Environment
What medications can trigger delirium?
tricyclic antidepressants
anticholinergics
benzodiazepines
tramadol
anti-histamines
Screening test for delirium?
4-AT Test
Components of 4-AT Test
Alertness (4)
AMT-4 (age, DOB, place, yr) (2)
Attention (2)
Acute change/fluctuating (4)
Delirium vs Dementia?
acute onset
altered consciousness/drowsiness
inattention
disorganised thinking
can have both -> not mutually exclusive
Treatment for delirium?
primarily non-pharmacological
treat any underlying cause
person -> minimise sensory deprivation, sleep deprivation, hydration, nutrition, elimination, engage family
environment -> keep constant, clocks right, calendars right, room with windows, items from home, limit restraints, discontinues unnecessary lines
occupation -> re-establish pre-existing routines, sleep hygiene, stimulate an appropriate amount
Pharmacological Treatment of Delirium?
anti-psychotics (haloperidol, risperidone, quetiapine, olanzapine)
start low, go slow
When is pharmacological treatment of delirium necessary?
if the patient is posing a risk to themselves or to other patients
last resort as does not treat the delirium and may in fact lengthen it
When are benzos used in delirium?
Alcohol/Benzo withdrawal
Patients with Parkinson’s or Lewy Body Dementia
Subtypes of dementia?
Alzheimer’s Disease
Vascular Dementia
Frontotemporal Dementia
Dementia with Lewy Bodys
Parkinson’s Dementia
Progressive Supranuclear Palsy
Corticobasal Degeneration
Pathology of Alzheimer’s Disease?
build-up of beta amyloid plaques and Tau protein neurofibrillary tangles
Presentation of Alzheimer’s?
gradually progressive decline in cognitive function
short-term memory affected first
neuropsychiatric symptoms common
Features of Vascular Dementia?
‘step-wise’ deterioration
associated with CVS risk factors and stroke
more acute than AD
Lewy Body Dementia vs Parkinson’s Disease Dementia?
dementia symptoms within 1 year of PD onset -> Lewy Body Dementia
dementia symptoms after more than 1yr with PD -> Parkinson’s Disease Dementia
Features of Lewy Body Dementia?
motor features of PD
cognitive impairment
visual hallucinations v common
Features of PD Dementia?
v similar to Lewy Body
early impairment in executive function
Features of Frontotemporal Dementia?
early decline in social interpersonal contact
emotional blunting
overlap with MND and PD
Evaluating Suspected Dementia Patient?
detailed Hx -> collateral is key
medication review (STOPSTART)
full exam
cognitive screening (MoCA, MMSE)
Bloods (Ca, U&Es, TFTs, B12 and folate, HIV/Syphillis)
ECG
neuroimaging
LP
Pharmacological Tx of Alzheimer’s Disease?
1st line -> cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
More severe -> memantine (NMDA receptor antagonist)
Non-pharmacological Tx for AD?
cognitive stimulation exercises
exercise
diet
early management of CVS RFs
support groups
art and music therapy
support for family and carers
Treatment of BPSD?
patient-centred psychosocial interventions
memantine
antipsychotics if risk to selves or others -> quetiapine
Members of MDT?
doctors
nurses
GP
OT
physio
SALT
Dieticians
Discharge Coordinator
Social Work
Osteoporosis Definition?
T-Score on DEXA <-2.5
or
prev. frailty fracture
What is a frailty fracture?
fracture from a fall from standing or sitting down
common sites include hip, wrist (FOOSH), pubic ramus
Blood results in osteoporosis?
Ca normal, phosphate normal, alk phos normal, PTH normal
Risk Factors for osteoporosis?
Incr. age
Female
post-menopause
FHx
red. mobility
long-term corticosteroid use
PPI use
low BMI
low Ca or Vit D intake
alcohol and smoking
prev fractures
CKD, hyperthyroidism, RA
Who should be screened for osteoporosis?
anyone on long-term corticosteroids
anyone with prev frailty fracture
anyone > 50 with RFs
women > 65
men > 70
How to screen for osteoporosis?
QFracture Tool
FRAX tool
How to diagnose osteoporosis?
DEXA scan gold standard but not always necessary
Management for Osteoporosis?
address modifiable RFs
supplement with Vit D and Ca
bisphosphonates first-line
denosumab
teripartide
Examples of bisphosphonates?
alendronate weekly oral
risedronate weekly oral
zoledronic acid yearly IV
How to take oral bisphosphonates?
first thing in morning
empty stomach
take and stay upright for 30 minutes to minimise GI SEs
Side Effects of bisphosphonates?
oesophagitis and oesophageal erosions
atypical femoral fractures
osteonecrosis of jaw
osteonecrosis of external auditory canal
hypocalcaemia
What is Denosumab?
monoclonal antibody that targets osteoclasts
How is Denosumab taken and for how long?
S/C injection every 6 months
initially cont. for 10 yrs but risk of rebound osteoporosis on stopping Tx
What is Teripartide?
PTH
anabolic function
daily injection
Parkinson’s Disease Symptoms?
Tremor
Rigidity
Akinesia/Bradykinesia
Postural instability
Postural hypotension
Sleep Disorders
Psychosis (visual hallucinations)
Depression/Dementia
Parkinson’s Pathology?
neurodegenerative disease caused by loss of dopaminergic neurons in the substantia nigra in the basal ganglia
Differentials for Tremor?
Parkinson’s Disease
Benign Essential Tremor
Cerebellar (intention) Tremor
Postural Tremor (lithium, inhalers, anxiety, hyperthyroidism)
PD Medications?
Dopamine Agonists (ropinirole, pramipexole)
MAOb inhibitors (selegeline, rasagiline)
Levodopa + prevent breakdown
SEs of dopamine agonists?
impulsive behaviour
nausea, constipation
nightmares
hallucinations
sleep attacks (NB for driving)
hypotension
Issues with medications for PD?
slow in the mornings waiting for effect to kick in
‘wearing off’ phenomenon
Parkinson’s + Conditions?
Multiple Systems Atrophy
Progressive Supranuclear Palsy
Corticobasilar Degeneration
Differentiating Multiple Systems Atrophy?
Parkinsonism +
autonomic dysregulation
orthostatic hypotension
urinary incontinence/retention
anhidrosis
Differentiating Progressive Supranuclear Palsy?
Parkinsonism +
vertical gaze palsy
axial rigidity with head tilted backwards
Differentiating Corticobasilar Degeneration?
speech problems
astereognosis
alien limb phenomenon
Key Features Suggestive of Stroke?
abrupt onset
focal neurological signs and symptoms
maximal deficit occurring within seconds
negative symptoms
What investigations if suspected stroke?
CT brain non-contrast (rule out haemorrhage, check for ischaemia)
CT angiogram (check for LVO)
CT perfusion (see infarcted areas and penumbra)
Acute Interventions for Stroke?
Thrombolysis and Thrombectomy
Time-set for thrombolysis?
Within 4.5hrs of onset of symptoms
Time-set for thrombectomy?
Within 24hrs of onset of symptoms
Assessing for cause of stroke?
Atherosclerosis of Large Vessels
Small Vessels arteriosclerosis
Cardio-embolic events
Others
What is the one thing that improves outcome in 100% of stroke patients?
Early admission to an acute stroke unit
Prevention of further strokes?
dual antiplatelet therapy for 3 wks (aspirin 300mg and clopidogrel 75mg)
monotherapy clopidogrel 75mg
statin therapy
BP <130/80
If AFib -> anticoagulate
Risk Factors for Stroke?
Age
A Fib
Prev. stroke or TIA
carotid artery disease
CVD
HTN
diabetes
smoking
vasculitis
thrombophilia
COCP
Initial management of suspected stroke?
exclude hypoglycaemia
CT brain non-contrast to rule out haemorrhagic stroke
aspirin 300mg
thrombolysis
thrombectomy if appropriate
don’t treat HTN (risk of hypoperfusion)
Management of TIA?
urgent referral to stroke specialist (24hrs)
aspirin 300mg daily
secondary prevention measures for CVD
Rehab for stroke?
MDT!!!!!!!!
doctors, nurses, OTs, physio, SALTs, dieticians, psychology, social work, discharge coordinators, family
What is syncope?
transient LOC and postural tone with spontaneous recovery
Discriminating syncope from other pathology?
Sudden Cardiac Death -> recovery in syncope
TIA -> no LOC in TIA
Seizure -> discriminating features include lateral tongue bite, faecal incontinence and recovery time
Causes of syncope?
Neurally-mediated
Cardiogenic
Neurally-mediated types of syncope?
vasovagal
situational
orthostatic hypotension
postprandial hypotension
carotid sinus syndrome
Cardiogenic types of syncope?
structural (aortic stenosis, HOCM, myxoma, dissection, PE)
arrhythmias (SVT, brady/tachyarrhythmias, Brugada Syndrome)
Diagnosing neurally-mediated syncope?
tilt-table test
orthostatic hypotension (>20mmHg systolic, >10mmHg diastolic)
carotid sinus massage
Diagnosing cardiogenic syncope?
CVS Exam (murmurs, HR)
ECG
CXR
Echo
Treatment for syncope?
explain and reassure
avoid precipitating factors
medication review (antihypertensives, anticholinergics, antidepressants)
Consequences of Urinary Incontinence?
psychosocial (embarrassment, depression, isolation, dec. self-esteem, institutionalisation)
medical (pressure ulcers, rashes, UTI, falls, fractures, red. mobility, red. ADLs)
Types of Urinary Incontinence?
Mixed
Functional
Urge/OAB
Overflow
Stress
Reversible causes of urinary incontinence?
Delirium
Infection
Atrophic vaginitis
Pharmaceuticals
Psychological
Excessive urine output
Restricted mobility
Stool impaction
What medications can cause urinary incontinence?
anti-cholinergics
diuretics
Treatment for urinary incontinence?
maximise independence (mobility, prompted voiding, avoid catheter)
minimise precipitants (caffeine, alcohol, weight loss)
muscle exercises (bladder retraining, pelvic floor exercises)
Medications for urinary incontinence?
try to avoid
inc. risk of falls, incontinence and retention, cognitive impairment
tamsulosin (alpha blocker)
finasteride (5 alpha reductase inhibitor)
oxybutynin (anti-cholinergic)
mirabegron (beta 3-adrenoceptor agonist -> best in elderly frail patients)
Confusion Screen Bloods?
FBC
U&Es
LFTs
coagulation screen
TFTs
Calcium
B12/Folate/Haematinics
Glucose
Blood cultures
Scale for assessing ADLs?
Barthel Index
Scales for assessing cognitive impairment?
AMTS (/10)
MoCA (/30)
MMSE (/30)
Scales for assessing degree of disability after a stroke?
Modified Rankin Scale (0-6)
Scale for quantifying stroke severity?
NIHSS (/42 -> thrombolysis advised if >4)
Scale for assessing frailty?
Clinical Frailty Scale (1-9)
Medications which increase risk of falls?
Antipsychotics
Benzos
Antidepressants
Antihypertensives
Diuretics
Anticholinergics
Medications which increase risk of orthostatic hypotension?
beta blockers
alpha blockers
diuretics
calcium channel blockers
DDx for Stroke?
Sepsis
Space-occupying lesion
Sugars -> hypoglycaemia
Seziures -> post-ictal weakness
Syncope
Sore -> migraine
Silly -> delirium
Stroke functional -> functional disorder
When is warfarin used over DOACs?
mechanical heart valve
antiphospholipid syndrome
eGFR < 15ml/min
Scale for assessing risk of pressure ulcers developing?
Waterlow Score
What is the MMSE test used for?
To assess cognitive function
What is the MoCA test used for?
To assess cognitive function
What is the AMTS used for?
To assess cognitive function (abbreviated)
What is the 4AT test used for?
To assess for delirium
What is the Barthel Index used for?
To assess a person’s independence in completing their ADLs
What is the Waterlow Score used for?
To assess for the risk of a person developing pressure ulcers
What is the Clinical Frailty Score used for?
To assess how frail a person is
What is the Modified Rankin Score used for?
To assess a person’s level of disability after a stroke
What is the NIHSS used for?
To assess the severity of a stroke and thus if the person will benefit from thrombolysis
What are senile purpura?
common benign condition characterised by the formation of ecchymosis on the extensor surfaces of the arm
What are pressure ulcers?
localised injury to tissue (usually over a bony prominence) as a result of pressure
Risk Factors for pressure ulcers?
exposure to sustained pressure and shear
immobility
increased age
incontinence
malnutrition
What is a stage 1 pressure ulcer?
non-blanching erythema of intact skin, usually over a bony prominence (sacrum)
What is a stage 2 pressure ulcer?
partial thickness skin loss or blistering
***reportable to HIQA
What is a stage 3 pressure ulcer?
full thickness skin loss with visible S/C fat
What is a stage 4 pressure ulcer?
full thickness tissue loss with exposed bone, muscle and tendon
***if exposed bone -> assume osteomyelitis
Management of pressure ulcers?
prevent further injury -> prevent pressure, friction, shearing
identify RFs and reduce if possible
promote new tissue growth
manage exudate
protect surrounding skin
remove devitalised tissue
promotion of granulation from base of wound
Prevention of pressure ulcer formation?
Skin Assessment (head to toe, focus on bony prominences)
Surface (special mattresses)
Keep moving
Incontinence
Nutrition (MUST score)
