Geriatrics Flashcards
What percentage of elderly patients admitted to hospital suffer delirium?
Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital.
What is the first line sedative in delirium? what if also has parkinsons?
haloperidol 0.5 mg as the first-line sedative
management can be challenging in patients with Parkinson’s disease, as antipsychotics can often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred
Describe the non-pharmacological management of alzheimers
Non-pharmacological management
NICE recommend offering 'a range of activities to promote wellbeing that are tailored to the person's preference' NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia other options to consider include group reminiscence therapy and cognitive rehabilitation
What is the pharmacological management of alzheimers disease?
Whats first line
Whats second line
NICE updated it’s dementia guidelines in 2018
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
Who is donepezil relatively contraindicated in?
Donepezil
is relatively contraindicated in patients with bradycardia adverse effects include insomnia
What are the 5 risk factors for alzheimers? is this genetic?
Risk factors
increasing age
family history of Alzheimer’s disease
5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
apoprotein E allele E4 - encodes a cholesterol transport protein
Caucasian ethnicity
Down’s syndrome
What are the macroscopic / microscopic / biochemical changes seen in alzheimers dementia?
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
hyperphosphorylation of the tau protein has been linked to AD
biochemical
there is a deficit of acetylcholine from damage to an ascending forebrain projection
What are neurofibrillary tangles?
Neurofibrillary tangles
paired helical filaments are partly made from a protein called tau tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules in AD are tau proteins are excessively phosphorylated, impairing its function
What are the assessment tools for dementia in the non-specialist setting? What assessment tool is not recommended?
assessment tools recommended by NICE for the non-specialist setting include: 10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT)
assessment tools not recommended by NICE for the non-specialist setting include the abbreviated mental test score (AMTS),
General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia
What tests are done in primary care when suspecting dementia? what tests are done in secondary care?
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 are 3 common causes of dementia?
Common causes
Alzheimer's disease cerebrovascular disease: multi-infarct dementia (c. 10-20%) Lewy body dementia (c. 10-20%)
What are 4 rarer causes of dementia
Rarer causes (c. 5% of cases)
Huntington's CJD Pick's disease (atrophy of frontal and temporal lobes) HIV (50% of AIDS patients)
What is frontotemporal lobar degeneration dementia?
Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer’s and Lewy body dementia.
There are three recognised types of FTLD
Frontotemporal dementia (Pick's disease) Progressive non fluent aphasia (chronic progressive aphasia, CPA) Semantic dementia
What are 4 common features of FTLD?
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
What is pick’s disease?
This is the most common type of FTLD and is characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
