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.
what are the macroscopic and microscopic changes seen in pcik’s diseasE?
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.
Macroscopic changes seen in Pick’s disease include:-
Atrophy of the frontal and temporal lobes
Microscopic changes include:-
Pick bodies - spherical aggregations of tau protein (silver-staining) Gliosis Neurofibrillary tangles Senile plaques
What should not be used in FTLD?
Management
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
what is the chief factor of CPA (Chronic progressive aphasia)
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
What are the features of semantic dementia?
Semantic dementia
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
What is the characteristic pathological feature of lewy body dementia?
Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas
What are three features of lewy body dementia?
Features
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)
What is the diagnosis of lewy body dementia?
Diagnosis
usually clinical single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100%
What can be used in lewy body dementia? what should be avoided?
Management
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.
What are 8 differentials when thinking about dementia?
Important differentials, potentially treatable
hypothyroidism, Addison's B12/folate/thiamine deficiency syphilis brain tumour normal pressure hydrocephalus subdural haematoma depression chronic drug use e.g. Alcohol, barbiturates
What drugs can cause postural hypotension? 7
Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta-blockers
L-Dopa
Angiotensin-converting enzyme inhibitors - (ACE) inhibitors
What bedside tests / blood tests / imaging should be considered in patients who have fallen?
Bedside tests Basic observations, blood pressure, blood glucose, urine dip and ECG
Bloods Full Blood Count, Urea and Electrolytes, Liver function tests and bone profile
Imaging X-ray of chest/injured limbs, CT head and cardiac echo
When should you offer a MDT assessment in patients who have fallen?
Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
>2 falls in the last 12 months A fall that requires medical treatment Poor performance or failure to complete the 'Turn 180° test' or the 'Timed up and Go test'
What is multimorbidity?
Definition
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
What are 6 risk factors for multimorbidity?
Risk factors
Increasing age Female sex Low socioeconomic status Tobacco and alcohol usage Lack of physical activity Poor nutrition and obesity
HOw can frailty be assessed?
Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire: The PRISMA-7 involves questions considering the age, sex, health problems, assistance required and walking aid use of the patient
What screening tools can be used in older people to recognise medicine safety concerns?
Consider the use of screening tools such as STOPP/ START in older people to recognise medicine safety concerns: STOPP identifies medications where the risk outweighs the therapeutic benefits in certain conditions and START suggests medications that may provide additional benefits ie proton pump inhibitors for gastroprotection in patients on medications increasing bleeding risk
What 4 factors can lead to pressure ulcers?
malnourishment
incontinence
lack of mobility
pain (leads to a reduction in mobility)
What score can be used to screen pressure ulcers?
The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
Describe the grading of pressure ulcers
Grading of pressure ulcers - the following is taken from the European Pressure Ulcer Advisory Panel classification system.
Grade Findings
Grade 1 Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2 Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister
Grade 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss
Describe the management of pressure ulcers
Management
a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis) consider referral to the tissue viability nurse surgical debridement may be beneficial for selected wounds
