Geriatrics Flashcards
What is dementia ?
disorders characterised by loss of memory + other cognitive abilities affecting IADLs + ADLs
- group of disease (like cancer)
what acronym can be sued for overall presentation of dementias ?
DIRE
- Decline in cognition (language, attention)
- Impairment (not keeping up with IADL + ADLs)
- Rule out delirium (acute state of confusion)
- Exclude mental disorders (depression, schizophrenia)
what are IADLS ? acronym
SHAFT
- Shopping
- Houskeeping
- Accounting
- Food prep
- Transportation
what are ADLs ? acronym >
DEATH
- Dressing
- Eating
- AMbulating
- Toilet
- Hygiene
what are the different types of dementia ? (5) most common ?
- Alzheimers disease (most common)
- Vascular
- Lewy body
- Frontotemporal
- Mixed (multiple types)
Describe the presenfiaotn of Alzheimers disease ? onset ? symptoms ?
gradual onset
- amnesia + neurocognitive deficits (amnesia, aphasia, apraxia, agnosia)
- Psychiatric symptoms: mood changes (depressed, anxious, irritability), psychotic symptoms (delusional misidentification
- activity; sundown activity
- lack of insight (don’t usually have knowledge of illness)
Alzheimers disease pathophysiology ?
caused by plaques made of beta amyloids
- tends to misgold => becomes sticky => clumping => large insoluble fibril s=> plaques => weaken communication + plasticity at synapses => neurodegeneration + neural death
How Is Alzheimers investigation ? diagnosed ?
- diagnosis made clinically
- bedside cognitive test
- FBC (rule out delirium)
- CSF testing (amyloid + tau biomarkers)
- Structural MRI (atrophy => shrinkage)
what found in css in alzeihmers disease ?
amyloid plaques + neurofibirially tau tangles
alzheimers epi ?
less than 1%
(20% >80, 50% >90)
F>M
Alzheimers disease management ?
can’t halt or reverse progression (so symptom reduction and slow progression)
- cholinesterase inhibitors (=> increase Ach in brain)
- Antidepressants and antipsychotics
What is vascular dementia ? pathophys
infarction, haemorrhage + small vessel changes cause damage to white + grey matter (loss of brain parenchyma)
- multiple infarcts exhaust the brains compensatory mechanisms
vascular dementia présentation ?
due to the vascular pathology, doesn’t present with specific sign or symptoms but series of stepwise decreases in cognition
what will be seen on imaging in vascular dementia ?
imagine of brain will show multiple areas of ischaemic damage to varying ages
vascular dementia mangment ? (2)
- Cholinesterase inhibitors
- Reduce stroke RF: atiplatelt therapy, BP control, statins, control DM
what causes dementia with leeway bodies ?
accumulation of leeway bodies in CNS: protein alpha-synuclein accumulations that affects synaptic communication + plasciticy
dementia will Lewy bodies presentation ? age of onset ?
earlier onset (staring around 50) + worse decline than Alzheimers
- visual hallucinations (distinctive features - visual Hal-lewy-cinations, often have insight that not real)
- cognitive defects (memory not affected as much, more attention + concentration)
- neuroleptic sensitivity
- sleep
- Parkinsonism
describe how sleep is affected in dementia with Lewy bodies ?
REM sleep behaviour disorder => thrashing + flailing while asleep
(often one of the first signs)
why should you be careful prescribing antipsychotics to a px with Lewy body dementia ?
greater risk of neuroleptic malignant syndrome
- don’t give em (easily mistaken with psychosis)
- AP => extrapyramidal SE, confusion, catatonia, neuroleptic malignant syndrome)
Lewy body dementia epi ?prognosis ?
M=F
4 yrs life expectancy form diagnosis (alzheiemrs is 5-10)
Lewy body dementia management ? avoid what ?
- cholonetsrase inhibitors
- antiparkinsonsims (levodopa)
- Avoid AP
what is frontotemporal dementia ? (2)
degeneration of the frontal + temporal lobes of brain => decline in cognition + inappropriate/impulseive behaviour
fronttemporal dementia pathophysiology ?
caused by focal neurodegeneration of the frontal or temporal lobes of the brain
- neuronal loss, gloss, microvascular changes
frontotemporal dementia presentation ?
- obliviousness (saying hurtful things, not respecting pals personal space)
- hyperorality (even inedible objects)
- disinihibition (hypersexual)
- apathy (indifference to self care)
frontotemporal dementia epi ?
quite rare
- earlier onset (45-65)
- M=F
- Familial link ?
frontotempora dementia mangmet ?
behavioural interventions, social wokr
- SSRIs
What is delirium ?
fast developing type of confusion that affects ability to focus of attention
What are the consequences of delirium (3) ?
- Can increase mortality
- Can increase number of patient that end up in care home
- increase length of hospital stay and risk of acquired infections
What is delirium generally caused by ?
results form underlying organic illness
What is the triad of delirium ?
- Acute confusion
- Disturbed consciousness
- Altered behaviour (hyper/hypoactivity)
Causes of delirium ? pneumonic
DELIRIUM
- Drugs (poly pharmacy, withdrawal from drugs)
- Eyes or ears (sensory defects - hearing aid, glasses)
- Low oxygen (MI, Stroke, PE)
- Infection: most common is chest or urinary infection
- Retention: urianry retention or constipation
- Ictal states
- Undernutrition: not eating or drinking properly
- Metabolic causes: diabetes, post op state
How common is delirium on post op ward ?
10-15% develop delirium
In what groups of people is delirium most common (4) ?
- ICU
- stroke
- hip fracture
- terminal illness
What investigations might you do for delirium ?
try to investigate for the cause
- Bloods: FBC (inflam marksers, U+E (metabolic problems), CROP, Calcium, glucose
- TFT
- Urinalysis
- Blood culture
- Sputum culture
Delirium Mx ?
- Recognise and investigate cuases
- Orientate the patient: hearing aids/glasses on, clock + calendar visible, display familiar personal items, encourage visits form family, consistent staffing
- Medication review
- If severe: medical sedation
name some potentially treatable causes of cognitive impairment ? (6)
- Depression
- Delirium
- Vitmin deficiecny
- Stroke
- Tumour
- Intoxication
What is BPPV ? what Stan for ?
Peign paroxysmal positional vertigo
- common cause of recurrent eps of vertigo, triggered by head movement
- common in older adults
is BPPV peripheral or central cause of vertigo ?
peripheral cause of vertigo
BPPV presentation ? triggered by ?
20-60s eps => asymptomatic inbetween
- triggered by turning head (running in bed)
- no hearing loss or tints
BPPV pahtophsyiolgy ?
calcium carbonate crystals (otoconia) become displaced in to the semicircular canals => disrupt endolymph flow => confuse vestibular system
what could displace otoconia in BPPV ? (aetiology)
displaced due to viral infection, head trauma, aging
(BPPV)
how is BPPH diagnosed ?
(Dix => Dx)
- Dix Hallpike manœuvre
what is dix hall pike manoeuvre for ? what does it aim to do ?
do diagnose BPPV
- move patients head to move endolymph through semi circular canal => trigger vertigo
How is BPPH treated ?
reply manoeuvre
what is employ manoeuvre for ? what does it aim to do ?
move crystals in semicircular canal to position that doesn’t disrupt endolymph
Nam some RF for falls ? (7)
- fear of falling
- vision changes (changing glasses)
- medications (which act on CNS)
- under/malnourishment: contributes to frailty + loss of muscle mass + strength)
- Diabetes: peripheral neuropathy
- Dementia: cognitive impairment
- Incontinence: rushed movement to bathroom
Name some RF for poor bone health ? (6)
- Low dietary calcium => low BMD + early bone loss
- Physical inactivity
- Tobacco + alcohol use
- Sex: female
- Hormones: high thyroid hormone, menopause (low oestrogen)
- Medications: steroids, SSRIs, PPIs
what is chronic Heart Failure ? specifically affects which bit fo the heart ?
clinical features of impaired heart function specifically function of LV
describe the pathophys of chronic HF and what this leads to ?
chronic back flow of blood to LA, pul veins, lungs => increase vol and pressure of blood => start to leak fluid => pulmonary oedema
what is normal ejection fraction ?
normal >50 %
what is heart failure with presence EF ?
clinical HF features with EF > 50% due to diastolic dysfunction
causes of chronic heart failure ?
- IHD
- vascular heart disease (aortic stenosis)
- hypertension
- arrthymias (AF)
- cardiomyopathy
HF presentation ?
- breathlessness 9worse on exertion)
- cough (frothy white/pink sputum)
- orthopnea
- paroxysmal nocturnal dyspnoea
- oedema
- fatigue
what is paroxysmal nocturnal dyspnoea ? associated with what ? pathophsycioloyg (3)
waking up in the night with sever attack of Sob, cough + wheeze (associated with HF)
- life flat => fluid settles
- resp centre less responsive during sleep (reduced RR despite hypoxia)
- low Ad during sleep so myocardium more relaxed
signs of HF ?
- tachycardia
- tachypnoea
- hypertension
- murmur (valvular heart disease)
- bilateral basal crackers
- raised JVP
- peripheral oedeem
what do bilateral basal crackles in person with HF indicate ?
pros pulmonary oedema
what investigations for HF ? (4)
- clinical assessment
- NT-proBNP
- ECG
- Echo
HF mangement ? overall Mx ?
- refer to cardiology
- medical
- procedural
what determines how quick the referral to cardiology must be for patient presenting with HF ?
depend on the NT-proBNP result
- 400-2000: within 6 weeks
- >2000: within 2 weeks
Medical management of HF ? (4)
ABAL
- ACEI
- BB
- Aldosterone antoagnosit
- Loop dieretic
What changes would be seen on XR in HF ?
ABCDE
- Alveolar oedema (bat wing opacification)
- Kerley B lines (interstitial oedema)
- Cardiomegaley
- Dilated upper lobe vessels
- Effusions (with blunted costophrenic angles)
Where and when is BNP produced ?
hormone produced mainly by the left ventricular myocardium in response to strain
What is reduced LVEF typically defined as ? what measures this ?
echocardiograph <35 to 40 %
(this is around half of the patients with HF)
What classification system can classify the severity of heart failure ? how many categories ?
New York Heart Association (NYHA) classification
class I - IV (worst)
what is is NYHA Class II ?
HF severity scale
- mild symptoms
- slight limitation of physical activity, comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
What is NYHA Class III ?
HF severity scale
- moderate symptoms
- marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
What blood test is first line in HF diagnosis ?
N-terminal pro_b-type natriuretic peptide (NT-proBNP)
What are some clinical sings of right sided heart failure ? (3)
- raised JVP
- Ankle oedema
- Hepatomegaly
Patient is on second line therapy for chronic heart failure. what drug types are they on ? and what electrolyte do they need to be cautious about/ monitored ?
ACEI, BB, aldosterone antagnost
- risk of hyperkalaemia (due to ACEI and AA)
What is osteoporosis ? osteopenia ?
condition here there is reduced density of bones ? osteopenia is a less reduced version
- low BMD => less strain => more prone to fractures
osteoporosis RF ? (6) which drugs associated with increased risk? (5)
- increasing age
- female (especially PM)
- reduced mobility
- low BMI
- alcohol and smoking
- low vit D and Ca diet
- long termcorticosteroids
- SSRI
- PPI
- Antiepileptics
- Antioestrogens (used in breast cancer)
what tool is used related to osteoporosis ? what does this calculate risk of ?
FRAX tool
- risk of fragility fracture in next 10 yrs
what assess BMD ? interpret the results ?
DEXA scan (reading at the hip)
- Z score (compared to someone their age)
- T Score (compared to healthy person): normal>-1, osteopenia -1 to -2.5, osteoporosis <-2.5
osteoporosis Mx ? first line ?
depend on FRAX score
- lifestyle changes
- calcium + vit D supplements
- Bishphosiphoantes (first lien treatment)
- HRT in PM women
modifiable RF for osteoporosis ? lifestyle changes ?
- increase activity
- maintain healthy weight
- increase dietary Ca and vit D
- avoid falling
- smoking cessation
- reduce alcohol
How do bisphosphanates work ? SE (3) how must they be taken ?
interfere with osteoclasts
- take on empty stomach + sit up for next 30 mins to prevent reflux
- SE: reflux, oesophageal erosions, atypical fractures
What scale used to assess frailty ? how many categories ?
Rockwood frailty scale
- 1 (very fit)
- 9 (Terminally ill)
What is multimorbidity ?
presence of 2 or more long term health conditions
Underlying medical conditions causing constipation ? (3)
- hypothyroidism
- multiple sclerosis
- structural abnormalities (haemorrhoids, anal fissure)
Medications causing constipation ? (4)
(iatrogenic)
- Opiods
- iron supplements
- tricyclic antidepressants
- Antipsychotics
name the different types of laxatives (4)
- Bulk forming
- osmotic
- stimulant
- stool softening
give example of bulk forming laxative ? how does it work ?
ispghula husk, methycellulose
- bulks out the stool with soluble fibre => increase faecal mass and stimulate peristalsis
(patients should increase fluid intake when taking this laxative type)
give example of somatic laxative ? how do they work ?
lactulose
- draw water via osmosis into stool => softer and easier to pass
give an example of stimulant laxative ? how do they work ?
Senna, sodium picosulfate
- stimulate the nerves of the digestive tract to cause peristalsis
where do pressure ulcers typically develop ?
bony prominences (sacrum or heel)
what scale is used to screen for patients at risk of developing pressure areas ?
Waterlow score
how many grades are there to pressure sores ? which is worse ? describe a bit
grades 1-4 (worse)
- 1: non-blanch able erythema, discolouration of skin
- 4: tissue encores, damage to muscle or bone
pressure sores management ? (3)
- moist wound environment encourage healing
- wound swabs (as often colonised with bacteria)
- surgical debridement
What is squamous cell carcinoma of the skin ?
common variant of skin cancer
- metastases may occur in 2-5% of patients
SCC of skin RF ?
- excessive exposure to sunlight
- immunosuppression
- smoking
SCC of skin Mx ?
surgical excision
definition of malnutrition ?
- BMI < 18.5
- unintentional weight loss greater than 10% within last 3-6 months
- BMI <20 plus unintentional weight loss greater than 5%
what screening tool is there for malnutrition ?
MUST (malnutrition universal screen tool)
- categorises into low, medium and high risk
what temperature counts as hypothermia ?
milk: 32-35
moderate or severe: <32
why avoid rapid re-warming in hypothermic patient ?
can lead to peripheral vasodilation and shock
