Geriatrics Flashcards

Question

What are the causes of a Haemorrhagic Stroke?

Answer 1

* Cerebral Amyloid Amyopathy (CAA): where beta peptide deposits in the walls of small blood vessels making them weak. * Hypertension * Aneurysms * Arteriovenous Malformations (AVM) * Trauma * Blood thinning medication

Answer 2

* Ipsilateral: facial pain and temperature loss * Contralateral: limb/torso pain and temperature loss * Ataxia, nystagmus

Answer 3

The patient is positioned lying on their back with both the hip and knee flexed at 90 degrees. The examiner then attempts to extend the patient's knee. If the patient experiences pain and resistance to knee extension, especially when attempting to straighten the leg, it is considered a positive Kernig's sign. This sign suggests meningeal irritation or inflammation.

Answer 4

The examiner gently flexes the patient's neck forward toward the chest while the patient is lying on their back. If the patient involuntarily flexes their hips and knees in response to neck flexion, it is considered a positive Brudzinski's sign.

Answer 5

* Severe headache * Altered consciousness, ranging from drowsiness to coma * Vomiting * Focal neurologic signs * Seizures * Hypertension

Answer 6

**Non-Contrast Head CT** - Is first line and diagnostic **MRI of the head** - Can help identify underlying causes MR Angiogram or Digital Substraction Angiography - Helps to identify vascular abnormalities that could have caused the bleed

Answer 7

After a head CT: **Surgical**: * Burr Hole Craniotomy (for Subdural haemorrhage) * Surgical Clipping or endovascular coiling (for Subarachnoid haemorrhage) **Pharmacological** * Hypertensive control * IV Fluids - To maintain cerebral perfusion * Nimodipine 60mg for 3/52 (CCB) - Reduces cerebral artery spasm (subarachnoid) * IV Mannitol - Reduces Intra-cranial pressure (Sub and extradural)

Answer 8

A sudden-onset transient focal neurological deficit with vascular aetiology, where typically, symptoms resolving in less than 1 hour. It's caused by focal brain, spinal chord or retinal ischaemia without evidence of acute infarction.

Answer 9

* Increased age * Male sex * hypertension * diabetes mellitus * high cholesterol * atrial fibrillation and carotid stenosis * smoking, * History of past TIAs / Strokes or cardio-embolic events. * Family history of cardiovascular disease / stroke

Answer 10

Sudden onset neurological deficits (**Most resolving within 1 hour**) * Speech difficulty (dysphasia) * Arm or leg weakness * Sensory changes * Ataxia, vertigo or loss of balance * Visual disturbances: Homonymous hemianopia, diplopia or Amaurosis Fungax

Answer 11

The sudden painless loss of vision in 1 eye Caused by an emboli passing into the retinal, ophthalmic or ciliary artery; causing temporary retinal hypoxia.

Answer 12

Ischaemic Stroke Haemorrhagic Stroke Migraine with Aura Focal Motor Seizures

Answer 13

Diffusion Weighted MRI Scan

Answer 14

* Blood Tests (glucose, lipid profile, clotting factors, LFTs, TFTs, CRP/ESR) * Carotid Ultrasound * Echocardiogram (looking for cardiac thrombus) * ECG looking for AF * Consider 24 Hour Tape (looking for paroxysmal AF)

Answer 15

**Immediate assessment (ideally within 24 hrs of symptoms) and referral to the TIA clinic** **Lifestyle modification** * Regular exercise * Smoking cessation * Healthy Diet **Control of vascular risk factors** * Hypertension (ACE inhibitor (e.g. ramipril), or ARB (e.g. candesartan) * Diabetes * Dyslipidaemia (start statin e.g. simvastatin 40mg) **Antiplatlet Therapy** * Immediate **Aspirin 300mg** * Patients with a High risk TIA or Low risk stroke (according to NIHSS <4) may be started on Dual antiplatelet Therapy (DAPT) * Aspirin + Clopidogrel 75mg **No driving until seen by specialist**

Answer 16

Is a condition characterised by sudden, episodic attacks of vertigo induced by changes in head position.

Answer 17

It's caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.

Answer 18

The calcium carbonate crystals can be displaced by: * viral infection * head trauma * ageing * Idiopathic

Answer 19

* Vertigo attacks provoked by specific head movements (like turning the head to one side while in bed or looking upwards) * Episodes of rotational vertigo lasting between 30 seconds to 1 minute * Recurrent episodes, often resolving naturally over weeks to months before re-occurring wekks-months later * Patients are asymptomatic between attacks **There is no hearing loss or tinnitus**

Answer 20

**Meniere's disease** episodic vertigo, tinnitus, hearing loss, and sensation of fullness in the ear **Vestibular neuritis** sudden onset severe vertigo, nausea, and imbalance lasting for several days **Labyrinthitis: vertigo** hearing loss, and tinnitus

Answer 21

**The Dix-Hallpike Manoeuvre** * Rapidly lower the patient to the supine position with an extended neck * A positive test **recreates the symptoms of benign paroxysmal positional vertigo** * **Rotatory nystagmus**

Answer 22

**The Epley Manouvre** This aims to move the detached otoliths out of the semicircular canal and back to the utricle where they originate. **Vestibular Rehabilitation with Brandt-Daroff exercises** can be done by the patient at home **Betahistine** medication is often prescribed but has limited effectiveness

Answer 23

It's an **acute and fluctuating** disturbance in attention and cognition causing a confusional state. Often accompanied by a change in consciousness. It is **typically reversible** and frequently seen in the elderly.

Answer 24

The prevalence increases with age, severity of illness and the presence of pre-existing cognitive impairment.

Answer 25

* Old Age * **Underlying Cognitive Impairment (Dementia)** * Previous History of Delirium * Frailty or multimorbidity * Polypharmacy * Sensory Impairment * Change of Environment

Answer 26

**P**ain **H**ypothermia/Pyrexia **O**rgan dysfunction (renal or hepatic impairment) **N**utrion **E**nvironmental changes **D**rugs and alcohol (OTC, illicit, Anti-cholinergics, Opiates, Anti-convulsants) **C**onstipation **H**ypoxia **I**nfection **M**etabolic disturbance (Electrolyte imbalance, Endocrinological issues, Wernicke's Encephalopathy) **P**olypharmacy **S**leep deprivation

Answer 27

**Where:** Disorientation **T**hought disorganisation **H**allucinations **E**nergy Changes: Can by **hyperactive or hypoactive** **F**luctuating **A**cute and Altered sleep **M**emory problems **I**nattention

Answer 28

**Hyperactive:** * Agitated * Hallucinations * Restless * Aggressive **Hypoactive:** * Withdrawn/Drowsy/Excessive sleeping * Calm and Quiet * Slowness with everyday tasks * Poor concentration/inattention * Reduced appetite **Delirium may present as a mixed picture containing features of both or fluctuate between the two. Hypoactive delirium is very hard to pick up**

Answer 29

* **Dementia:** Characterized by gradual onset, stable consciousness level, and progressive decline in cognitive function. * **Psychosis:** May present with hallucinations and delusions, but usually with preserved orientation and memory. * **Depression:** May exhibit poor concentration and slow cognition, but typically with a stable consciousness level and often accompanied by pervasive feelings of sadness or guilt. * **Stroke:** Abrupt onset with focal neurologic signs and specific deficits in speech, motor, or sensory function.

Answer 30

* Comprehensive physical examination and history * Abbreviated Mental Test Score (AMTS) * Confusion Screen (including bloods and urinalysis and imaging) * Imaging (possibly Head CT/MRI, Chest XRay or ultrasound of the abdomen depending on scenario) * ECG

Answer 31

**Blood Tests:** * FBC (infection, anaemia, malignancy) * U&Es (hyponatraemia, hypernatraemia) * LFTs (liver failure with secondary encephalopathy) * Coagulation/INR (intracranial bleeding) * TFTs (hypothyroidism) * Calcium (hypercalcaemia) * B12 + folate/haematinics (B12/folate deficiency) * Glucose (hypoglycaemia/hyperglycaemia) * Blood cultures (sepsis) **Urinalysis:** * UTI is a very common cause of delirium in the elderly **Imaging Studies:** * CT Head: if concerned about intracranial bleeding, stroke, ischaemia or abscess * Chest X-ray: If concerned about pneumonia or pulmonary odema

Answer 32

* Providing an environment with good lighting * Maintaining a regular sleep-wake cycle * Regular orientation and reassurance * Ensure patients pain is controlled * Use same staff * Put patients in side room where there is less noise * Ensuring the patient's glasses and hearing aids are used if needed

Answer 33

**Treat underlying cause of Delirium** Small doses of haloperidol or olanzapine/Lorazepam/Midazolam. To be used with caution and only in patients who are extremely agitated and present a danger to themselves or others

Answer 34

**Delirium** * Acute * Fluctuant * Reversible * Often have sleep disturbance/consciousness fluctuation * Underlying pathology/cause **Dementia:** * Progressive * Constant * Irreversible * Typically unaltered sleep patterns (in early stages) * Brain dysfunction

Answer 35

**Decline in memory** with impairment of at least one other cognitive function such as **skilled movements, language or executive function.** * A progressive condition which usually requires progressive cognitive decline for >6 months to be diagnosed.

Answer 36

* **Alzheimer's Disease** (accounts for 60-80% of cases) * Vascular Dementia * Lewy Body Dementia * Fronto-temporal Dementia * Mixed Dementia

Answer 37

* Depression * B12 and Folate Deficiency * Hypothyroidism * Normal Pressure Hydrocephalus (NPH)

Answer 38

**Behavioural and Psychological Symptoms of Dementia** * Psychosis: Hallucinations and Delusions * Excitation: Agitation and Aggression * Mood Disorders: Depression, Apathy, Emotional withdrawal, Anxiety

Answer 39

**Cognitive Stimulation Therapy**

Answer 40

Alzheimer's disease is a chronic, neurodegenerative disorder characterised by the progressive accumulation of abnormal protein deposits, primarily amyloid plaques and tau tangles, in the brain. This leads to the deterioration of cognitive function, memory loss, and various behavioural and psychological symptoms.

Answer 41

Increasing prevalence with age Women more commonly affected than men APOE Gene Alzheimer's is the most common cause of dementia (>50%)

Answer 42

**Amyloid Plaques:** The accumulation of beta-amyloid protein fragments outside nerve cells in the form of plaques is a hallmark feature. These abnormal protein deposits are believed to disrupt neuronal communication, trigger inflammation, and ultimately lead to cell death. **Tau Tangles:** Inside nerve cells, abnormal tau protein accumulates, forming neurofibrillary tangles. **Neuronal Loss and Brain Atrophy:** As the disease progresses, significant neuronal loss occurs, particularly in brain regions responsible for memory and cognitive function, such as the hippocampus and the cerebral cortex.

Answer 43

**Age**: Advanced age is the most significant risk factor >65yrs **Genetic Predisposition**: apolipoprotein E (APOE) gene, Down's syndrome **Family History**: Having a first-degree relative with Alzheimer's disease **Cardiovascular Risk Factors**: Conditions like hypertension, diabetes, obesity, and hypercholesterolemia **Lifestyle Factors**: Physical inactivity, smoking, and a diet high in saturated fats may contribute to increased risk. **Traumatic Brain Injury**: A history of head injuries, particularly repeated concussions, has been linked to a higher risk of developing Alzheimer's disease. **Low Educational Attainment**: Lower levels of education may be associated with an increased risk.

Answer 44

**Memory Impairment** **Language Impairment** **Executive Dysfunction** - impaired planning, organisation, and activities of tasks **Behavioural Changes** **Psychological Symptoms** **Disorientation** **Loss of Motor Skills**

Answer 45

Agitation Aggression Apathy Mood swings Irritability

Answer 46

Hallucinations Delusions Paranoia (in later stages)

Answer 47

Vascular Dementia Lewy Body Dementia Frontotemporal Dementia Mild Cognitive Impairment (MCI) Normal Age related Decline

Answer 48

* Six Item Cognitive Impairment Test (6CIT) * 10-point Cognitive Screener (10-CS) * Mini-Cog * General Practitioner Assessment of Cognition (GPCOG) * Montreal Cognition Assessment (MoCA)

Answer 49

**Screening assessment** **Required to exclude physical cause before referral** * Confusion screen (Bloods, Urine, Imaging) **Referral to Memory Clinic** * Addenbrooke’s Cognitive Examination-III (ACE-III) * < 88/100 suggests possible dementia

Answer 50

* Attention * Memory * Language * Visuospatial function * Verbal fluency **Scored out 100** * < 88 suggests possible dementia

Answer 51

Once reversible courses of confusion are eliminated and dementia is still suspected: * Brain imaging - MRI or PET scanmay show brain atrophy or presence of amyloid plaques * CSF Analysis may be used to detect specific biomarkers associated with AD

Answer 52

* Lasting Power of Attorney * Advanced decisions * Planning future care

Answer 53

**Non-pharmacological**: * **Cognitive Stimulation Therapy** * Psychological interventions * Activities to promote wellbeing (walking) * occupational therapy **Pharmacological**: * First line: **Acetylcholinesterase inhibitors** (rivastigamine, galantamine, and donpezil) in mild-moderate dementia * Second line: **Memantine** (NMDA inhibitor) in severe dementia **Treatment of BPSD** * Antidepressants (SSRIs) * Antipsychotics (risperidone) * Benzodiazepines (in acute crisis) **There is no curative treatment**

Answer 54

Vascular dementia is an umbrella term denoting a collection of cognitive impairment syndromes caused by cerebrovascular disease. These syndromes include stroke-related vascular disease, subcortical vascular dementia, and mixed dementia (a combo of alzheimer's and vascular)

Answer 55

Increasing prevalence with age More common in men Risk higher in people with cardio risk factors Its the second most common type of dementia (15-20%)

Answer 56

The primary cause is ischemic or haemorrhagic cerebrovascular disease, which leads to brain damage. Various different vascular events or conditions can lead to vascular dementia including: * multi-infarct and single-infarct dementia * subcortical vascular dementia (known as Binswanger's disease) * **(CADASIL)** Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

Answer 57

They mirror those of stroke and CVD: * hypertension * diabetes mellitus * hyperlipidemia * smoking * atrial fibrillation

Answer 58

It's characterised by a progressive, stepwise deterioration in cognition. This typically occurs over a span of several months to years. Patients may present with a history of strokes.

Answer 59

Alzheimer's disease Lewy body dementia Frontotemporal dementia Normal pressure hydrocephalus

Answer 60

**Comprehensive history and examination** **Cognition screening** - MMSE (Mini-Mental State Examination) or MoCA (Montreal Cognitive Assessment) **Medication review** - to exclude medication-induced cognitive impairment. **MRI Scan** show white matter changes **Exclusion of reversible organic causes** - like vitamin B12 or folic acid deficiency, hypothyroidism, or normal pressure hydrocephalus.

Answer 61

**MRI Head** - To identify vascular changes or infarcts

Answer 62

**Detection and address of CV risk factors** * hypertension, diabetes, hyperlipidaemia and smoking **symptomatic treatment** * Tailored to the individual * Include: **cognitive stimulation programmes**, multisensory stimulation, music and art therapy, animal-assisted therapy * Managing challenging behaviours e.g. address pain, avoid overcrowding, clear communication

Answer 63

Frontotemporal dementia is a heterogeneous group of neurodegenerative disorders characterised by progressive atrophy of the frontal and/or temporal lobes of the brain. Leading to impairments in behaviour, personality, language, and motor functions.

Answer 64

* Frontotemporal Dementia (**Picks Disease**) * Progressive Non Fluent Aphasia * Semantic Dementia

Answer 65

It's one of the most common forms of early onset dementia. Typically develops in peoples' 60s and 70s

Answer 66

Onset before 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change, disinhibition, language impairment and social conduct problems

Answer 67

**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

Answer 68

**Personality change and impaired social conduct.** Other common features: * Hyperorality * Disinhibition * Increased appetite * Perseveration behaviours. **Language impairment is another common feature**

Answer 69

Patients often exhibit disinhibited behaviour and apathy early on.

Answer 70

**Alzheimer's disease** **Vascular dementia** **Creutzfeldt-Jakob disease** Rapidly progressive dementia with neurological signs like myoclonus, ataxia, and visual disturbances. Periodic sharp wave complexes on EEG are suggestive. **Primary progressive aphasia** Characterised by gradual, insidious decline in language abilities with relative preservation of other cognitive functions.

Answer 71

**Neuroimaging (like CT and MRI)** Would show atrophy of frontal and/or temporal lobe **Genetic Testing** Used in cases where an inherited form of FTD is suspected

Answer 72

**Non-Pharmacological** **Cognitive Stimulation Therapy** Counselling Behaviour modification strategies Caregiver support Speech and language therapy Physiotherapy Occupational therapy **Pharmacological** SSRIs and Antipsychotics to control behavioural symptoms **There is no curative treatment**

Answer 73

It's a type of rapidly progressive dementia caused by deposits of an abnormal protein (alpha-synuclein) forming cytoplasmic inclusions known as Lewy bodies within brain cells. These aggregates disrupt normal cell functioning and eventually lead to neuronal death.

Answer 74

Abnormal protein (alpha-synuclein) forming cytoplasmic inclusions known as Lewy bodies within brain cells. Accumulate in: * Substantia nigra * Paralimbic * Neocortical areas.

Answer 75

Parkinson's Disease

Answer 76

* **Fluctuating cognition** compared to other forms of dementia * **REM sleep disorder** (often the initial symptom) * **Parkinsonism** * **Recurrent Visual hallucinations** * High sensitivity to neuroleptics (antipsychotics)

Answer 77

They can induce or worsen parkinsonism They can also cause neuroleptic malignant syndrome

Answer 78

**Alzheimer's disease** **Parkinson's disease dementia** It shares many symptoms with DLB, but Parkinson's disease dementia tends to start with motor symptoms year before cognitive decline. **Vascular dementia**

Answer 79

**Careful History and clinical examination** (Diagnosis is primarily clinical) **CT/MRI Head** May be normal or show cortical atrophy **Dopamine transporter (DaT) scan** Can help distinguish DLB from other types of dementia.

Answer 80

**Pharmacological** * **AchE inhibitors** (Donepazil, Rivastigmine) and **Memantine** can be used * **Neuroleptics should be avoided** due to the risk of irreversible parkinsonism **Non-Pharmacological** * Cognitive stimulation therapy * Physical therapy * Occupational therapy **Supportive Care** * Palliative and end-of-life care considerations (due to its progressive nature)

Answer 81

Due to the high risk of developing irreversible parkinsonism

Answer 82

It's a condition where there is a progressive reduction in dopamine in the basal ganglia, leading to disorders of movement. The symptoms are characteristically asymmetrical, with one side of the body affected more. The typical patient is an older man, around 70 years old, with a gradual onset of symptoms.

Answer 83

**Resting tremor** (a tremor that is worse at rest) **Rigidity** (resisting passive movement) **Bradykinesia** (slowness of movement)

Answer 84

Prevalence increases with age More common in males

Answer 85

The accumulation of Lewy Bodies within the dopaminergic cells of the substantia nigra of the basal ganglia; leading to their neuronal death and the reduction of dopamine.

Answer 86

Family History Male Sex Increasing Age Being a non-smoker - Smoking reduces the risk of Parkinson's

Answer 87

**Triad of Parkinsonism** Bradykinesia Asymmetric 3-5Hz "pill-rolling" tremor Lead pipe rigidity This can manifest in a **Parkinsonian gait** (small, shuffling steps, slowness of movement, especially on initiation and turning, flexed posture, and asymmetric tremor) Other features: * Hypomimic facies * Cogwheeling when testing tone

Answer 88

Depression Sleep disturbance and insomnia Loss of the sense of smell (anosmia) Postural instability (increasing the risk of falls) Constipation Erectile Dysfunction Cognitive impairment and memory problems

Answer 89

* **Multiple System Atrophy** - Presents with early autonomic dysfunction and postural instability compared to PD * **Lewy Body Dementia** - Early and prominent cognitive dysfunction before parkinsonism traits. (**Visual Hallucinations**) * **Progressive Supranuclear Palsy** * **Corticobasal Degeneration**

Answer 90

* **Benign Essential Tremor** * **Multiple System Atrophy (MSA):** Very prominent autonomic dysfunction, early postural instability, poor response to levodopa * **Dementia with Lewy Bodies (DLB):** Early and prominent cognitive dysfunction, visual hallucinations, fluctuating cognition * **Progressive Supranuclear Palsy (PSP):** Early gait instability and falls, vertical gaze palsy, prominent axial rigidity * **Corticobasilar Degeneration:** May have predominant apraxia, aphasia and 'alien hand' syndrome * **Wilson's Disease:** May be associated with signs of liver disease * **Dementia Pugilistica:** Secondary to repeated head trauma

Answer 91

Parkinson's disease is primarily a clinical diagnosis, supported by positive response to treatment trials. An absolute failure to respond to 1-1.5g of levodopa daily almost excludes a diagnosis of idiopathic Parkinson's disease. Other investigations such as MRI Head or a Dopamine Transporter Scan (DaT scan) can be considered in atypical cases. **The NICE guidelines recommend that the diagnosis is made using the UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria**

Answer 92

Tx focused on Symptom control and minimising side effects: **Levodopa** (combined with Decarboxylase inhibitors **Carbidopa / Benserazide**) * **Co-beneldopa** (levodopa and benserazide), with the trade name **Madopa** * **Co-careldopa** (levodopa and carbidopa), with the trade name **Sinemet** **COMT Inhibitors** - Decarboxylase inhibitor to prevent breakdown of L-DOPA **MOA Inhibitors** - Inhibit the breakdown of neurotransmitters such as dopamine and serotinin. **Dopamine Agonists** - Mimic action of Dopamine

Answer 93

Osteoporosis is a systemic skeletal disease characterised by **reduced bone mass and altered microarchitecture** of the bone tissue, leading to increased bone fragility and a consequent increase in fracture risk. It is typically defined by a **DEXA scan T-score of -2.5 or lower**

Answer 94

Higher prevalence with increasing age Most common in postmenopausal women and elderly men.

Answer 95

Age Female Gender

Answer 96

**S**teroid use **H**yperthyroidism, hyperparathyroidism **A**lcohol and smoking **T**hin (BMI<22) **T**estosterone deficiency **E**arly menopause **R**enal/liver failure **E**rosive/inflammatory bone disease **D**iabetes

Answer 97

It tends to be asymptomatic until a fracture occurs * Back pain, caused by a fractured or collapsed vertebra * Loss of height over time * A stooped posture * A bone fracture that occurs much more easily than expected

Answer 98

Bone Mineral Density and Bone mass is reduced however the mineralisatoin of bone is unchanged in Osteoporosis. **Bone remodelling imbalance** * Increased bone resorption from osteoclasts * Reduced bone formation by osteoblasts * Reduction in both bone mineral density and matrix density reducing bone mass. **Bones Brittle and Fragile** * Reduced bone density and mass * Causes brittle and fragile bones **Increased fracture risk**

Answer 99

**Metabolic bone diseases** e.g. osteomalacia and hyperparathyroidism - presents with low bone mass and increased fracture risk. **Malignancies** e.g. multiple myeloma or metastatic disease, which can lead to pathologic fractures similar to those seen in osteoporosis. **Secondary causes of osteoporosis** e.g. Cushing's syndrome, hyperthyroidism, and certain medications (e.g., glucocorticoids, anticonvulsants).

Answer 100

**DEXA Scan (Stands for Dual-Energy X-Ray Absorptiometry)** A bone mineral density T-Score of -2.5 is diagnostic of osteoporosis. Its measured at the hip

Answer 101

* History and physical examination * FBC * U&Es (serum calcium, creatinine, phosphate) * LFTs (ALP, transaminases) * TFTs * 25-OH vit D & 1,25-OH vit D * Serum testosterone & prolactin * Lateral radiographs of lumbar and thoracic spine * Protein immunoelectrophoresis and urinary Bence-Jones protein

Answer 102

* Age * Gender * Weight/Height * Previous Fracture * Previous Femoral neck BMD * Parental Hip Fracture * Current Smoking * Glucocorticoid Use * Rheumatoid Arthritis * Secondary Osteoporotic conditions * Alcohol use (> 3 units/day)

Answer 103

* Glucocorticoid use * rheumatoid arthritis * alcohol excess * history of parental hip fracture * low body mass index * current smoking

Answer 104

Type I diabetes osteogenesis imperfecta long-standing hyperthyroidism hypogonadism premature menopause (<45 years) chronic malnutrition or malabsorption disorders (IBD, Coeliac) Chronic Kidney disease Chronic liver disease

Answer 105

**Glucocorticoids** SAPGAL: S: SSRIs A: Antiepileptics P: Proton pump inhibitors G: Glitazones A: Aromatase inhibitors (e.g., anastrozole) L: Long term heparin use

Answer 106

Q Fracture Tool (preferred by NICE) FRAX Tool Q Fracture tool > 10% are sent for DEXA

Answer 107

**Step 1: Is there a history of fragility fracture?** * No = Move on to step 2 * Yes = Move on to step 2 if age < 50 OR perform DEXA if age > 50 OR Make clinical diagnosis if age ≥ 75 **Step 2: Perform fragility fracture risk assessment (FRAX/Qfracture)** * Low risk = Repeat risk assessment after 5 years * High-Intermediate risk = perform DEXA

Answer 108

* Anyone on long-term oral corticosteroids or with a previous fragility fracture * Anyone 50 and over with risk factors * All women 65 and over * All men 75 and over

Answer 109

**Lifestyle modification** * Reducing risk factors like quitting smoking, improving diabetic control, reduce alcohol consumption and increasing exercise. * Adequate intake of vitamin D (400-800 IU), Calcium (at least 1000mg), and protein * Regular weight-bearing exercise * Use of hip protectors in nursing home patients

Answer 110

**First line: Oral Bisphosphonates** * Oral Alendronate 70 mg once weekly (oral) * Oral Risedronate 35 mg once weekly (oral) **1st line after NOF** * IV Zoledronic acid 5 mg once yearly (intravenous) **Second Line:** * Denosumab

Answer 111

bisphosphonates bind to hydroxyapatite in bone, inhibiting osteoclast-mediated bone resorption

Answer 112

human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

Answer 113

On an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.

Answer 114

Reflux, Oesophagitis and oesophageal erosions Atypical fractures (e.g., atypical femoral fractures) Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment) Osteonecrosis of the external auditory canal

Answer 115

Intra-Capsular Neck of Femur Fracture

Answer 116

**Intracapsular Fractures (subcapital):** edge of the femoral head to the insertion of the capsule of the hip joint * Occur within the joint capsule * Non-Displaced * Displaced (**High risk of avascular necrosis of the femoral head**) **Extracapsular Fractures** * Occur outside the joint capsule * Intertrochanteric * Subtrochanteric fractures * Better prognosis due to a lower risk of avascular necrosis.

Answer 117

**Garden System** Type I: Stable fracture with impaction in valgus Type II: Complete fracture but undisplaced Type III: Displaced fracture, usually rotated and angulated, but still has boney contact Type IV: Complete boney disruption **Avascular Necrosis is a high risk in Types III and IV**

Answer 118

Prevalence increases with age More common in Females

Answer 119

Due to the increased prevalence of osteoporosis in the elderly. As well as the increased prevalence of conditions like dementia, parkinson's etc... that lower cognition and make them more likely to fall.

Answer 120

* Fall onto side in the elderly * High energy trauma like car accidents in the young

Answer 121

* Severe pain in the hip or groin * Inability to bear weight on the affected leg * Shortening and external rotation of the affected leg * Swelling or bruising over the hip area

Answer 122

Intertrochanteric Fracture Pelvic Fracture Hip Dislocation

Answer 123

Hip X-Ray If unclear on X-Ray then a CT Scan or MRI

Answer 124

**Non-displaced Fracture:** * internal fixation, or hemiarthroplasty if unfit. * Uses a Cannulated Hip Screw **Displaced Fracture:** * NICE recommend replacement arthroplasty to all patients with a displaced intracapsular hip fracture * **Total hip replacement** is favoured to hemiarthroplasty if patients: * Were able to walk independently out of doors with no more than the use of a stick * Are not cognitively impaired and * Are medically fit for anaesthesia and the procedure.

Answer 125

* Allows for early mobilisation and good pain relief which can prevent complications such as pressure sores and DVT, * Shorter operation time reducing perioperative risk in frail age group * Rehabilitation is quicker and easier

Answer 126

* stable intertrochanteric fractures: dynamic hip screw * **if reverse oblique, transverse or subtrochanteric fractures**: intramedullary device

Answer 127

Because the elderly are at an increased risk of falling and its virtually impossible to dislocate (v. hard) to dislocate a hemi. Where a THA would dislocate a lot more easily.

Answer 128

Tibial Shaft Fracture

Answer 129

* High-energy trauma, such as motor vehicle collisions or falls from a height * Sports-related injuries * Low-energy trauma, particularly in individuals with weakened bone structure, (e.g.those with osteoporosis)

Answer 130

* Severe pain in the lower leg * Swelling and tenderness around the injury site * Visible deformity if the fracture is displaced * Inability to bear weight on the affected leg * Possible open wound if the fracture is compound

Answer 131

* **Fibular fracture:** Typically presents with localized pain and swelling along the outer aspect of the lower leg * **Ankle fracture:** Usually associated with significant ankle pain, swelling, and instability * **Compartment syndrome:** Characterized by severe pain, paresthesia, and tenseness of the compartment involved * **Sprain or strain:** Usually less severe pain and swelling, with no obvious deformity

Answer 132

X-Ray CT Scan in complex or comminuted fractures to guide surgical planning

Answer 133

**Immobilization** The use of a cast or splint to protect the fracture and promote healing **Pain control** Analgesics, including NSAIDs or opioids **Surgical intervention** Open reduction and internal fixation (ORIF) or Intramedullary nailing **Rehabilitation**

Answer 134

* Classically follows a fall onto an outstretched hand (known as a FOOSH) * **Distal radius fracture** with dorsal displacement of fragments * Described as a dinner fork type deformity

Answer 135

* Transverse fracture of the radius * 1 inch proximal to the radio-carpal joint * Dorsal displacement and angulation **Colles':** **D**orsally **D**isplaced **D**istal Radius --> **D**inner fork **D**eformity

Answer 136

**Early** * median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion * compartment syndrome * vascular compromise * malunion * rupture of the extensor pollicis longus tendon **Late** * osteoarthritis * complex regional pain syndrome

Answer 137

It's defined the failure of the heart to generate sufficient cardiac output to meet the metabolic demands of the body.

Answer 138

Prevalence increases with age (avg age is 75) Coronary artery disease, Hypertension and valvular diseases are common causes in the West Chagas disease is a significant cause in Central/South America

Answer 139

**Ejection Fraction** (most common): * Reduced Ejection Fraction (HF-rEF) where EF is < 40% * Mildly reduced Ejection Fraction Where EF is 41-49% * Preserved Ejection Fraction (HF-pEF) where EF > 50% **Systolic/Diastolic Dysfunction** (replaced by HF-rEF and HF-pEF) * HF-rEF is typically a problem with Systolic function * HF-pEF is typically a problem with Diastolic function **By Time:** * Acute heart failure: Either new presentation or typically an acute exacerbation of chronic HF due to sudden LV failure and pulmonary oedema * Chronic heart failure **By Left/Right** **Output:** * Low-Output HF: Pump is not working to meet demands * High-Output HF: Pump works but demands are increased

Answer 140

Is much more common than High-Output HF Occurs when cardiac output is reduced due to a primary problem with the heart and the heart is unable to meet the body's needs.

Answer 141

It refers to a heart that has a normal cardiac output, but there is an increase in peripheral metabolic demands that the heart is unable to meet.

Answer 142

* Anaemia * Arteriovenous malformation * Paget's disease * Pregnancy * Thyrotoxicosis * Thiamine deficiency (wet Beri-Beri)

Answer 143

Systolic dysfunction refers to an impairment of ventricular contraction. The ventricles are able to fill well, but the heart is unable to pump the blood sufficiently out of the ventricle due to impaired myocardial contraction during systole (**reduced ejection fraction**).

Answer 144

* Ischaemic heart disease * Dilated cardiomyopathy * Myocarditis * Infiltration (haemochromatosis or sarcoidosis)

Answer 145

Diastolic dysfunction refers to the inability of the ventricles to relax and fill normally. Hence the heart is still able to pump well but pumps out less blood per contraction due to reduced diastolic filling (**preserved ejection fraction**).

Answer 146

* Uncontrolled chronic hypertension (significant left ventricular hypertrophy reduces filling of the left ventricle) * Hypertrophic Obstructive Cardiomyopathy (HOCM) * Cardiac tamponade * Constrictive pericarditis

Answer 147

Acute heart failure may be a **new presentation** of heart failure or, may be, **deterioration or 'decompensation'** in a person with existing chronic heart failure.

Answer 148

Left HF causes pulmonary congestion (pressure builds up on the Left hand side of the heart and there is back pressure to the lungs) and there is systemic hypoperfusion.

Answer 149

**Symptoms** * **Fatigue** * Shortness of breath on exertion * Dyspnoea * Orthopnoea (breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) * Paroxysmal nocturnal dyspnoea * Nocturnal cough (± pink frothy sputum) **Signs** * Tachypnoea * Bibasal fine crackles on auscultation of the lungs * Cyanosis * Prolonged cap refill time * Hypotension Less common signs: pulsus alternans (alternating strong and weak pulse), S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle), features of functional mitral regurgitation.

Answer 150

Describes the experience that patients have of suddenly waking at night with a severe attack of shortness of breath, cough and wheeze. They may describe having to sit on the side of the bed or walk around the room, gasping for breath. They may feel suffocated and want to open a window to get fresh air. Symptoms improve over several minutes.

Answer 151

Right heart failure causes venous congestion (pressure builds up behind the right heart) and pulmonary hypoperfusion (reduced right heart output).

Answer 152

**Symptoms** * **Fatigue** * Ankle swelling * Weight gain * Abdominal swelling and discomfort * Anorexia (cardiac cachexia) and nausea **Signs** * Raised JVP * Pitting peripheral oedema (ankle to thighs to sacrum) * Tender smooth hepatomegaly * Ascites * Transudative pleural effusions (typically bilaterally)

Answer 153

Left Heart Failure

Answer 154

It classifies Heart Failure through the severity of symptoms. There are 4 classes: **Class I**: No limitation on activity **Class II**: Comfortable at rest but symptomatic with ordinary activities **Class III**: Comfortable at rest but symptomatic with any activity **Class IV**: Symptomatic at rest

Answer 155

**Chronic Obstructive Pulmonary Disease (COPD)** Both present with dyspnoea (and significant respiratory distress) and fatigue. **Acute Respiratory Distress Syndrome** Both present with shortness of breath, tachypnoea and respiratory distress. Both lead to the accumulation of fluid in the lungs and impaired gaseous exchange leading to hypoxaemia. **Renal Failure** Both present with fluid retention and peripheral overload. **Liver Failure** Both present with fluid retention and peripheral overload (especially ascites)

Answer 156

In heart failure the shortness of breath is typically worse on lying flat (orthopnoea) and may be accompanied by paroxysmal nocturnal dyspnoea and peripheral oedema. Shortness of breath in COPD tends to be worse with exertion and is likely accompanied with other symptoms including chronic productive cough, wheeze and a significant smoking history.

Answer 157

They can be distinguished by taking pulmonary capillary wedge pressures. The underlying pathology between the two is different. Heart failure is a result of raised pressures in pulmonary capillaries, whereas ARDS is usually due to increased pulmonary capillary secondary to a large insult (e.g. pneumonia, aspiration, or trauma).

Answer 158

**NT-Pro-BNP level** It's released by the ventricles in response to myocardial stretch. It has a high negative predictive value.

Answer 159

* 2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks. * 400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks. * If <400ng/L be aware that diagnosis of heart failure is less likely.

Answer 160

Transthoracic Echocardiogram

Answer 161

ECG Bloods (U+Es, LFTs, TFTs, Glucose and Lipid profile) Chest X-Ray

Answer 162

**A**: Alveolar oedema (with 'batwing' perihilar shadowing) **B**: Kerley B lines (caused by interstitial oedema) **C**: Cardiomegaly (cardiothoracic ratio >0.5) **D**: upper lobe blood diversion **E**: Pleural effusions (typically bilateral transudates) **F**: Fluid in the horizontal fissure

Answer 163

* Weight loss if BMI >30. * Smoking cessation * Salt and fluid restriction - improves mortality * Supervised exercise-based group rehabilitation programme for people with heart failure.

Answer 164

**Symptomatic Treatment:** Loop Diuretics (furosemide, Budesonide) but have no role in mortality reduction **First Line HF Medications:** * Beta-Blocker (Bisoprolol, Carvedilol) and ACE Inhibitor (ramipril) * ARB (e.g. Candesartan) is used if intolerant to ACE-I **Second Line HF Medications:** * Aldosterone Antagonists (Spironolactone, Eplerenone) * Monitor potassium as Aldosterone antagonists and ACEi will cause Hyperkalaemia * SGLT-2 Inhibitors (Dapagliflozin) is a recommended ad on to standard care **Third Line HF Medications:** * Ivabradine if in sinus rhythm >75/min and EF < 35%. * Sacubitril-Valsartan (ARNI) for EF <35% and Symptomatic on ACEi/ARB * Hydralazine and a nitrate for Afro-Caribbean patients. * Digoxin is used in patients with co-existent AF. **Other Treatments:** * Annual Influenza Vaccine * One off Pneumococcal Vaccine

Answer 165

**Beta blockers**: Bradycardia, hypotension, fatigue, dizziness, ED **ACE inhibitors**: Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema **Spironolactone**: Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido **Furosemide**: Hypotension, hypoatraemia/kalaemia, **Hydralazine/nitrate**: Headache, palpitations, flushing **Digoxin**: Dizziness, blurred vision, GI disturbances

Answer 166

Any or all of the following: * Fewer than three bowel movements per week * Hard stool in more than 25% of bowel movements * Tenesmus (sense of incomplete evacuation) in more than 25% of bowel movements * Excessive straining in more than 25% of bowel movements * A need for manual evacuation of bowel movements

Answer 167

**Primary constipation**: No organic cause, thought to be due to dysregulation of the function of the colon or anorectal muscles **Secondary constipation**: Due to factors such as diet, medications, metabolic, endocrine or neurological disorders or obstruction

Answer 168

Advanced age Inactivity Low calorie intake Low fibre diet Certain medications Female sex

Answer 169

**Dietary factors** like inadequate fibre or fluid intake **Behavioural factors** like inactivity or avoidance of defecation **Electrolyte disturbances** like hypercalcaemia **Certain drugs** like opiates, calcium channel blockers and some antipsychotics **Neurological disorders** like spinal cord lesions, **Parkinson's disease** and diabetic neuropathy **Endocrine disorders** such as hypothyroidism **Colon diseases** like strictures or malignancies **Anal diseases** like anal fissures or proctitis

Answer 170

* Infrequent bowel movements (less than 3 per week) * Difficulty passing bowel motions * Tenesmus * Excessive straining * Abdominal distension * Abdominal mass felt at the left or right lower quadrants (stool) * Rectal bleeding * Anal fissures * Haemorrhoids * Presence of hard stool or impaction on digital rectal examination

Answer 171

Weight loss Loss of appetite Abdominal mass Dark stool

Answer 172

**Irritable Bowel Syndrome (IBS)** Characterized by abdominal pain, bloating, and alternating constipation and diarrhea **Inflammatory Bowel Disease (IBD)** Presents with abdominal pain, weight loss, and bloody diarrhea **Anal fissures** Characterized by severe anal pain during and after bowel movements, and bright red blood in the stool **Hemorrhoids** Symptoms include painless rectal bleeding, anal itching, and discomfort **Colorectal Cancer** Symptoms include changes in bowel habits, rectal bleeding, and unintentional weight loss

Answer 173

**Clinical Diagnosis following History, examination and potentially DRE** **Ix to consider if secondary cause** * Full blood count * Electrolytes * Thyroid function tests * Blood glucose * Abdominal x-ray if suspicious of a secondary cause of constipation * Barium enema if suspicious of impaction or rectal mass * Colonoscopy if suspicious of lower GI malignancy

Answer 174

**Investigate and exclude any secondary causes, consider red flag symptoms** * Exclude any faecal impaction **Advice on lifestyle** * increasing dietary fibre * ensuring adequate fluid intake * ensuring adequate activity levels **Pharmacological** * First-line laxative: bulk-forming laxative first-line, such as ispaghula * Second-line: osmotic laxative, such as a macrogol * Enemas (e.g., sodium citrate) if impaction is present

Answer 175

* Enemas (e.g., sodium citrate) if impaction is present * Suppositories such as glycerol * Bulk laxatives such as ispaghula husk or methylcellulose * Stool softeners like docusate sodium * Osmotic laxatives like lactulose or macrogol * Stimulant laxatives like senna or bisacodyl

Answer 176

* overflow diarrhoea * acute urinary retention * haemorrhoids * Delirium * Faecal impaction

Answer 177

Stress incontinence Urge incontinence Overflow incontinence Mixed incontinence

Answer 178

It involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder. The pressure of the urine overcomes the mechanisms designed to maintain continence and it's caused by a weakness of the pelvic floor and sphincter muscles. Acts like coughing, laughing, sneezing or exercising can increase abdominal pressure sufficiently.

Answer 179

**Childbirth** (especially vaginal). Due to a combination of injury to the pelvic floor musculature and connective tissue, as well as nerve damage. **Hysterectomy**

Answer 180

**Conservative** * Lifestyle Advice like avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake. * Pelvic Floor Exercises **Medical Management** * Duloxetine (only if conservative has failed and surgery isn't an option) **Surgical Management** * Incontinence pessaries (are placed transvaginally and apply pressure to the anterior vaginal wall) * Bulking agents (injectable materials placed at the bladder neck to improve continence). * Colposuspension and fascial slings * **Mid-urethral slings are the gold standard surgical treatment of stress incontinence.**

Answer 181

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. It's is also known as overactive bladder and the typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs.

Answer 182

Recurrent urinary tract infections High BMI Advancing age Smoking Caffeine

Answer 183

**Conservative** * Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line * Lifestyle Advice like avoiding caffeine, fizzy and sugary drinks, as well as avoiding excessive fluid intake. * Pelvic Floor Exercises **Medical Management** * Anticholinergic medication (oxybutynin, tolterodine and solifenacin) * Mirabegron as an alternative **Surgical Management** * Bladder Instillation (Involves the Intravesical injection of Botox can be used to paralyse the detrusor muscle) * Percutaneous sacral nerve stimulation (implanting a device in the back that stimulates the sacral nerves)

Answer 184

Dry mouth Dry eyes Urinary retention Constipation Postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia,

Answer 185

Uncontrolled hypertension It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. Which can lead to a hypertensive crisis and an increased risk of TIA and stroke.

Answer 186

It's a combination of urge incontinence and stress incontinence.

Answer 187

It occurs when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine.

Answer 188

* Underactivity of the Detrusor muscle (can be caused by neurological damage) OR * When urinary pressures are too high can be caused by constipation or prostatism)

Answer 189

**Bladder diary** Tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. **Urine dipstick** To assess for infection, microscopic haematuria and other pathology. **Bladder Scan** To measure post-void residual bladder volume to assess for incomplete emptying **Urodynamic testing** Can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis.

Answer 190

They're a way of objectively assessing the presence and severity of urinary symptoms. Tests Involved: **Cystometry** measures the detrusor muscle contraction and pressure **Uroflowmetry** measures the flow rate Leak point pressure is the point at which the bladder pressure results in leakage of urine. **Post-void residual bladder volume** tests for incomplete emptying of the bladder

Answer 191

It's a Nutrient deficiency state of protein, energy or micronutrients (vitamins and minerals). NICE definition: * BMI < 18.5 * Unintentional weight loss greater than 10% within the last 3-6 months * BMI < 20 and unintentional weight loss greater than 5% within the last 3-6 months

Answer 192

* Living alone. * Institutionalisation or hospitalisation. * People with severe learning difficulties or mental health problems (depression, dementia). * Diseases that affect appetite, eating/swallowing or gastrointestinal function (gastric surgery, malabsorption, * Poor physical function - eg, caused by stroke and neurological disorders such as motor neurone disease). * Catabolic states.

Answer 193

Weight Loss (often insidious in adults) Listlessness. Increasing fatigue. Cold sensitivity. Non-healing wounds and severe decubitus ulcers.

Answer 194

**MUST Score (Malnutrition Universal Screening Tool)** * Done on admission to care/nursing homes and hospital or if there is concern

Answer 195

Impaired physical function e.g. infection, malignancy, renal or heart failure Depression Dementia

Answer 196

* General nutritional advice * Dietician support if patient is high risk * **Food first approach** * Use of Supplements as second line taken between meals rather than instead of meals * Refer to Social Services - if the problem is inability to shop or prepare meals * Refer to Occupational Therapy - If the problem is difficulty with eating utensils

Answer 197

**Clinical Assessment** Assess for co-existing dehydration, infection, anaemia or hypoglycaemia **Correct shock and dehydration and restore electrolyte balance** (feeding) **Reverse Malnutrition through artificial feeding** Without overloading cardiac, renal, GI or hepatic function

Answer 198

Refeeding syndrome is a serious and potentially life-threatening condition that can develop in malnourished patients when they begin to reintroduce food after a period of starvation or fasting. It can occur with various different malnourishment backgrounds e.g. anorexia, alcoholism, prolonged fasting, etc...

Answer 199

It's caused by the reintroduction of glucose, or sugar, into the body after a period of malnutrition or fasting. During fasting, the body adapts to use fat and protein as its primary energy sources. When carbohydrates are reintroduced, insulin secretion resumes, leading to a shift in electrolytes which can disrupt the function of various organs.

Answer 200

**Low phosphate levels** muscle weakness, hemolysis, respiratory failure, and neurological symptoms like delirium and seizures. **Low magnesium levels** neuromuscular excitability, muscle weakness, and cardiac arrhythmias. **Low potassium levels** muscle weakness, paralysis, and potentially fatal cardiac arrhythmias. **Hyperglycemia** symptoms of diabetes, such as increased thirst and urination, fatigue, and blurred vision.

Answer 201

A core body temperature of < <35°C This leads to the hypothalamus releasing TSH, ACTH and causing shivering as a process to warm the body up.

Answer 202

**Mild** (32°C to 35°C): characterised by tachycardia, tachypnoea, vasoconstriction and shivering **Moderate** (28°C to 32°C): may have cardiac arrhythmias, hypotension, Bradycardia, respiratory depression, reduced consciousness and may cease to shiver. **Severe** (<28°C): markedly reduced consciousness/coma, apnoea, arrhythmia, fixed and dilated pupils

Answer 203

* Bradyarrhythmias e.g. sinus bradycardia, atrial fibrillation with a slow ventricular response, slow junctional rhythms and varying degrees of AV block * **Osborne Waves** ('J waves') = positive deflection at the J point between the end of the QRS and beginning of the ST segment * Prolonged PR, QRS and QT intervals * Shivering artefact * Ventricular ectopics * Cardiac arrest (VT, VF or asystole)

Answer 204

**Remove the patient from cold environments or cold and wet clothes** * Passive Warming is 1st line e.g. covering the patient with a warm blanket and supplying warm drinks * Intravenous administration of warmed fluid * Application of warmed air (e.g. using a bear hugger) Patients are at a high risk of cardiac arrest and CPR may be required.

Answer 205

General anaesthesia Substance abuse Hypothyroidism Impaired mental status Homelessness Extremes of age

Answer 206

Everyone has the right to liberty and security of person. No one shall be deprived of his or her liberty [unless] in accordance with a procedure prescribed in law.

Answer 207

A procedure in law used where it is necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm.

Answer 208

* The person must be 18 or over. * The person must be suffering from a mental disorder. * The person must be a patient in hospital or a resident in a care home. * The person lacks capacity to decide for themselves about the restrictions which are proposed so they can receive the necessary care and treatment. * The proposed restrictions would deprive the person of their liberty. * The proposed restrictions would be in the person's best interests. * Whether the person should instead be considered for detention under the Mental Health Act. * There is no valid advance decision to refuse treatment or support that would be overridden by any DoLS process.

Answer 209

* Every adult is assumed to have capacity unless proved otherwise * A person must be given all practicable help to make their own decisions before they are deemed to lack capacity * People are allowed to make unwise or unsafe decisions * All treatment must be done in a patients best interests * Anything done must be done in the least restrictive way possible

Answer 210

**Understand** the decision **Retain** the information long enough to make the decision **Weigh up** the pros and cons **Communicate** their decision

Answer 211

A legal document drawn up by a competent adult that nominates another person to make decisions on their behalf

Answer 212

It's a medical decision made by a patient with capacity, regarding their future wishes for treatment. It only comes into force if a patient subsequently lacks capacity

Answer 213

A single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person

Answer 214

**Poor Physical Health** **Mental Illness** Cognitive impairments (eg, dementia) or Behavioral disorders (eg, depression) **Poverty and Disruptive Living Environment** **Demographic Risk Factors** More common in women, increased prevalence with increased age

Answer 215

* Multiple ED visits for similar injuries * A delay of greater than 24 hours in reporting injuries or responding to the needs of an elderly patient * A history of abuse * A patient with risk factors

Answer 216

Is a term used to describe the simultaneous use of multiple medications by a patient Its especially common in the elderly who are more likely to have multiple chronic conditions

Answer 217

* Increased risk of falls * Reduced adherence and concordance * It increases the risk of drug side effects * Increases the risk of drug interactions

Answer 218

They occur when skin and underlying tissues are placed under pressure that impairs blood supply, leading to tissue damage. They're caused by pressure and/or shear forces over a bony prominence (e.g. sacrum)in the presence of risk factors; primarily among these is immobility

Answer 219

They present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures e.g. muscle and bone.

Answer 220

* malnourishment * incontinence: urinary and faecal * lack of mobility * pain (leads to a reduction in mobility)

Answer 221

Waterlow score / Braden Scale

Answer 222

Grade 1: Red, intact skin. Grade 2: Partial skin loss, looks like a blister or abrasion. Grade 3: Full skin loss, damage down to fat layer. Grade 4: Severe tissue damage, may involve muscle or bone.

Answer 223

* Repositioning of the patient * Pressure-relieving support surfaces * Local **wound management using moist hydrogels** and hydrocolloid dressings * Pain relief with paracetamol (**NSAIDs are not used** as they can increase peripheral oedema) * Infection control * Potentially Abx if surrounding cellulitis * consider referral to the tissue viability nurse * surgical debridement may be beneficial for selected wounds

Answer 224

A SCC is a locally invasive malignant tumour of epidermal keratinocytes.

Answer 225

* excessive exposure to sunlight / psoralen UVA therapy * actinic keratoses and Bowen's disease * immunosuppression e.g. following renal transplant, HIV * smoking * long-standing leg ulcers (Marjolin's ulcer) * genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism

Answer 226

* Typically on sun-exposed sites such as the head and neck or dorsum of the hands and arms * Rapidly expanding painless, ulcerate nodules * May have a cauliflower-like appearance * There may be areas of bleeding/ulceration

Answer 227

Punch biopsy

Answer 228

Excision Biopsy with a 4mm margin (or 6mm for high risk lesions)

Answer 229

**Good Prognosis** * Well differentiated tumours * < 20mm diameter * < 2mm deep * No associated diseases **Poor Pronogsis** * Poorly differentiated tumours * > 20mm diameter * > 4cm deep * Immunosuppression

Answer 230

* Its almost always treated surgically with excision using a 4mm margin (6mm in high risk lesions) * Sometimes Mohs Microsurgery is used * Radiotherapy is sometimes required * Lifestyle advice (use suncream) * Plastic surgery if the lesion is tricky to remove

Answer 231

Pseudodementia is a condition primarily associated with cognitive deficits in older patients suffering from **depression**

Answer 232

* Short duration of symptoms mimicking dementia * Equal impact on long-term and short-term memory * Amnesia concerning specific, often emotionally charged, events * Detailed complaints about memory disturbances * Early loss of social skills in the disease progression * Common responses of “don't know” to questions, rather than attempting to guess * Minimal effort in task performance

Answer 233

Comprehensive cognitive assessments and psychiatric evaluations.

Answer 234

Management primarily involves treating the underlying depressive disorder: * Cognitive behavioural therapy * Antidepressant medication With appropriate treatment, cognitive symptoms usually improve or resolve.

Answer 235

It's a medical condition characterised by complex visual hallucinations in individuals who are partially sighted or visually impaired, but otherwise cognitively healthy.

Answer 236

**Causes of visual impairment** * Age related macular degeneration * Glaucoma * Cataracts

Answer 237

Advanced age Peripheral visual impairment Social isolation Sensory deprivation Early cognitive impairment

Answer 238

Diagnosis mainly rests on clinical presentation and patient history. Neurological and ophthalmic examinations can be done to rule out other potential causes of visual hallucinations. **Must occur in the absence of any other significant neuropsychiatric disturbance**

Answer 239

Involves addressing the underlying cause which may involve: * Addressing the visual impairment * Providing psycological support * Possible pharmacological intervention

Answer 240

Its defined as a fall of >20mmHg in Systolic blood pressure or >10mmHg in Diastolic blood pressure within 3 minutes of standing.

Answer 241

**4 Is** * Immobility * Instability (falls) * Incontinence * Impaired Cognition (Delirium/Dementia) * Other specific symptoms: Chest pain, SOB, Urinary symptoms

Answer 242

**History of falls** is strongest RF Lower limb muscle weakness Vision problems Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson's disease etc) Polypharmacy (4+ medications) Incontinence >65 Have a fear of falling Depression Postural hypotension Arthritis in lower limbs Psychoactive drugs Cognitive impairment **Home trip hazzards**

Answer 243

**Assessment of Falls Risk** * **Timed Up and Go Test** * **Turn 180 degree Test** **Bedside Tests** * A-E assessment * Basic Observations * BP * Blood Glucose * Urine Dip * ECG **Investigations to Consider** * Bloods: FBC, U&E, LFTs, Bone profile * Imaging: X-ray of chest/injured limbs, CT head, ECHO

Answer 244

* Strength and balance training — most likely to benefit older community-dwelling people with a history of recurrent falls or balance and gait deficit. * Home hazard assessment and intervention — should be offered to older people who have received treatment in hospital following a fall. * Vision assessment and referral. * Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible.

Answer 245

Describes the deterioration in function that occurs in the context of an acute illness. Being stuck in hospital and bed bound causes many problems such as muscle wasting and worsening nutritional states. This means it takes longer for them to recover and would requrie Physical and Occupational therapy input.

Answer 246

**Multidisciplinary approach** Focuses on determining a frail older person's **Medical, psychological and functional** capabilities to enable the development of a co-ordinated and integrated plan for treatment and long term follow-up

Answer 247

A distinct age related health state characterised by a **reduction in physiological reserve** resulting in adverse outcomes following minor stressor events

Answer 248

* Not Irreversible * Not Inevitable * Not simply due to multiple long term conditions

Answer 249

* Good nutrition * Physical activity (especially when younger) * Avoidance of social isolation * Reducing smoking and alcohol intake

Answer 250

**Phenotype** (fried criteria) **Cumulative Deficit** (CFS, e-FI)

Answer 251

**Description of a Phenotype** Frailty was defined as a clinical syndrome of 3 or more of: * Unintentional weight loss * Self-reported exhaustion * Weakness (grip strength) * Slow walking speed * Low physical activity

Answer 252

**1. Very Fit:** People who are active and considered "the fittest for their age" **2. Well:** No active disease symptoms but they exercise often or are very active occasionally **3. Managing Well:** Medical problems are well controlled but not regularly active beyond routine walking **4. Vulnerable:** Not dependent on others for help but symptoms limit activities **5. Mildly Frail:** More evident slowing and may require help with High order IADLs (finances, transport, heavy housework) **6. Moderately Frail:** Need help with all outside activities and with keeping house. May require help with stairs and bathing but minimal assistances with dressing **7. Severely Frail:** Completely dependent on personal care from whatever cause. They are however stable and not at high risk of dying within 6 months **8. Very Severely Frail:** Completely dependent on care and approaching the end of life. Typically they could not recover from a minor illness **9. Terminally ill:** Approaching end of life with a life expectancy of <6 months who are not otherwise evidently frail.

Answer 253

A process of discussion about goals of care and means of setting on record preferences for care of patients who may lose capacity or communicating ability in the future.

Answer 254

* Legal Aspects: Advanced Directives to Refuse Treatment (ADRT) or Lasting Power of Attorney (LPoA) * Preferred place of care * Treatment options acceptable to patient and suitable for patient (ReSPECT form) * DNACPR decisions * Specific plan for complex scenarios

Answer 255

**MDT Approach** * Physiotherapy and exercise * Dietician for Nutritional support * Doctors/pharmacists for medication review of polypharmacy and care of co-morbidities * Occupational therapy for ADLs help and reducing falls risk * Social support

Answer 256

A state of undernutrition

Answer 257

* Reduced Nutrient Intake (starvation) * Increased Nutrient Requirement (Sepsis/Injury) * Inability to utilise nutrients ingested (malabsorption: coeliac, IBD, IBS etc) * Combination of above

Answer 258

* Reduced immune system * Muscle wasting leading to increased risk of falls, chest infections, reduce mobility and inactivity * Impaired wound healing * Micronutrient deficiencies (B12 deficiency causing neurological deficit)

Answer 259

**Malnutrition Universal Screening Tool** Scores a patient based on their: * **BMI:** * **History of weight Loss:** * **Acute Disease Effect:**

Answer 260

* **Food first approach** (unless severely malnourished): Snacks, nourishing drinks and food fortification * **Oral Nutritional Supplements:** Fortisips * **Enteral/Parenteral Nutrition:** NG tube, PEG, Parenteral feeding

Answer 261

Direct feeding into the gut (stomach, duodenum, Jejunum) **Advantages:** * Preserves Gut Mucosa and Integrity * Improves nutritional status * Inexpensive compared to parenteral nutrition **Disadvantage:** * Tolerance: nausea, satiety, bowels * Tube can be uncomfortable to place * Patient QoL

Answer 262

**Short Term:** * Nasogastric (NG) Tube * Nasojejunal (NJ) Tube **Long Term:** * Percutaneous Endoscopic Gastrostomy (PEG) * Percutaneous Endoscopic Jejunostomy (PEJ)

Answer 263

* Dysphagia * Cystic fibrosis - high nutritional requirements * Oral nutritional intake inadequate and likely to be a long term option

Answer 264

IV feeding when the gut is inaccessible or unable to absorb sufficient nutrients to sustain nutritional status

Answer 265

* Inadequate absorption (eg. short bowel syndrome) * Gastrointestinal fistula * Bowel obstruction * Prolonged Bowel Rest * Severe malnutrition

Answer 266

A serious and potentially life-threatening condition that can develop in malnourished patients when they begin to reintroduce food after a period of starvation or fasting.

Answer 267

* A patient who is severely malnourished will be running fat stores and fat metabolism. * It results from a shift in use of energy stores from fat metabolism to carbohydrate metabolism. * This increases insulin release which results in the cellular uptake of **potassium, phosphate and magnesium** causing a shift in fluids and electrolytes. * This will result in fluid retention, cardiac arrhythmias, respiratory insufficiency and even death

Answer 268

* **Low phosphate levels:** This can lead to muscle weakness, haemolysis, respiratory failure, and neurological symptoms like delirium and seizures. * **Low magnesium levels:** This can lead to neuromuscular excitability, muscle weakness, and cardiac arrhythmias. * **Low potassium levels:** This can result in muscle weakness, paralysis, and potentially fatal cardiac arrhythmias. * **Hyperglycaemia:** This can lead to symptoms of diabetes, such as increased thirst and urination, fatigue, and blurred vision.

Answer 269

* IV Pabrinex or Thiamine + Vitamin B co-strong prior to re-feeding and for the first 10 days * Slow introduction of nutrition to prevent fluid and electrolyte shifts * Daily monitoring of **refeeding bloods:** * U&Es * Phosphate * Magnesium * Potassium

Answer 270

Abrupt decline in kidney function that occurs within hrs to days due to a rapid decline in GFR leading to a failure to maintain fluid, electrolyte and acid-base homeostasis. It is usually (but not always) reversible.

Answer 271

Rise in creatinine of ≥ 25 micromol/L in 48 hours Rise in creatinine of ≥ 50% in 7 days Urine output of < 0.5ml/kg/hour for > 6 hours

Answer 272

Increase Serum Creatinine by 1.5-1.9x Baseline Decrease Urine output <0.5mg/kg/hr for 6-12hrs

Answer 273

Increase Serum Creatinine by 2-2.9x Baseline Decrease Urine output <0.5mg/kg/hr for >12hrs

Answer 274

Increase Serum Creatinine by 3x Baseline Decrease Urine output <3.5mg/kg/hr for >24hrs or during RRT Anuria for >12 hours

Answer 275

AKI affects 10-20% of all hospitalized patients and up to 50% of critically ill patients in intensive care.

Answer 276

* Age 65 years or over * Chronic kidney disease * Other organ failure/chronic disease e.g. heart failure, liver disease, diabetes mellitus * History of acute kidney injury * Nephrotoxic Drug use * Use of iodinated contrast agents within the past week * Illness/infection and sepsis

Answer 277

**Pre-renal:** (most common) Due to inadequate blood supply reaching the kidneys reducing filtration of blood. **Renal:** Where there is intrinsic disease within the kidney that leads to the reduced filtration of blood **Post renal:** Caused by obstruction to the outflow of urine from the kidney, causing back-pressure into the kidney and reduced kidney function. This is called an obstructive uropathy

Answer 278

* Dehydration * Hypotension (shock, Sepsis, Anaphylaxis) * Renal artery stenosis/obstruction * NSAIDs/ACEi * Liver/Heart failure

Answer 279

* Acute tubular necrosis * Glomerulonephritis * Acute interstitial nephritis * Haemolytic uraemic syndrome * Rhabdomyolysis

Answer 280

* Kidney stones * Tumours (e.g., retroperitoneal, bladder or prostate) * Strictures of the ureters or urethra * Benign prostatic hyperplasia (benign enlarged prostate) * Neurogenic bladder

Answer 281

**D**iuretics **A**CEi/ARBs/Aminoglycosides (gentamicin) **M**etformin/Methotrexate **N**SAIDs

Answer 282

Impaired ability of the kidneys to filter the blood. This leads to accumulation of substances that are usually excreted: * Potassium ions * Urea * Fluid * H+ ions Can lead to damage of the nephron and kidney

Answer 283

* Oliguria/Anuria * Dehydration * Nausea and vomiting * Confusion * Fever (sepsis) * Uraemia: Weakness, tremor, fatigue, nausea, vomiting, mental confusion, seizures and coma * Breathlessness: Combination of anaemia and pulmonary oedema secondary to volume overload * Acid build up - Metabolic acidosis

Answer 284

**Blood Tests:** * FBC * U&Es * LFTs * Glucose * Clotting * Bone profile * Creatinine Kinase (CK) * CRP **Arterial Blood Gas (ABG):** To assess for acidosis, hypoxia and an urgent potassium level **Urinalysis:** * Dipstick: looking for blood or protein * Microscopy, Culture and Sensitivities: To exclude infection * Urine protein:creatinine ratio **ECG:** To identify Hyperkalaemia **Chest X ray:** To identify pulmonary oedema if fluid overloaded **Renal Ultrasound:** For Obstruction, structural kidney disease or hydronephrosis

Answer 285

**Urea:Creatine Ratio** * U:Cr > 100:1 = pre-renal * U:Cr < 40:1 = renal * U:Cr 40-100:1 = Post renal

Answer 286

**Generally Supportive if haemodynamically stable** * Ensure kidneys are perfused but not overloaded * Medication review and STOP nephrotoxic meds * Monitoring for complications (Hyperkalaemia, Uraemia, Acidosis)

Answer 287

**A**cidosis (severe metabolic acidosis with pH of <7.20) **E**lectrolyte imbalance (resistant hyperkalaemia) **I**ntoxication (drug overdose, poisoning) **O**edema (refractory pulmonary oedema) **U**raemia (encephalopathy or pericarditis)

Answer 288

* Fluid overload, heart failure and pulmonary oedema * Hyperkalaemia which can lead to arrhythmias * Metabolic acidosis * Uraemia (high urea), which can lead to encephalopathy and pericarditis