Geriatrics

Question 1

First Line Pharmacological Intervention in Alzheimers Disease

Answer 1

Pharmacological treatments may have modest benefits, and include the **cholinesterase inhibitors ** :

rivastigamine
galantamine
donepezil

in mild-moderate dementia,

and the **NMDA inhibitor **
memantine

in severe dementia (as classified using the MMSE score: severe: <10; moderate: 10-20; mild: 21-26/30.

If there is evidence of behavioral and psychological symptoms of dementia (BPSD), low-dose risperidone may be started

Question 2

What are the symptoms of delirium tremens?

Answer 2

agitation
rapid onset of confusion
tremor
sweating
visual hallucinations that tend to be of small animals or insects
Tachycardia

This is a complication of alcohol withdrawal that occurs after 3-4 days

Question 3

Define Postural Hypotension

Answer 3

A fall of > 20 mmHg systolic or > 10mmHg Diastolic

Question 4

Cerebellar Signs (of stroke) can be remembered with the acronym ______

Answer 4

DANISH

Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech (dysarthria)
Hypotonia

Question 5

A total anterior circulation infarct (TACI) is defined by:

Answer 5

Contralateral hemiplegia or hemiparesis, AND

Contralateral homonymous hemianopia, AND

Higher cerebral dysfunction (e.g. aphasia, neglect)

A TACI involves the anterior AND middle cerebral arteries on the affected side.

Question 6

In Ischaemic Stroke, what should the taget systolic BP be within one hour of admission?

Answer 6

The management of haemorrhagic stroke should include reversal of any anticoagulation (using beriplex/octaplex +/- vitamin K) and aggressive BP control. The systolic BP should be kept **<140mmHg within an hour of admission and ideally kept above 120mmHg. **

This can be done with Glyceryl Trinitrate (GTN) or labetalol infusion but also GTN patches

Question 7

Contraindications to thrombolysis

Answer 7

recent head trauma

GI or intracranial haemorrhage

recent surgery

acceptable BP

platelet count

INR

Question 8

Cranial nerve lesions are ipsilateral, except ____

Answer 8

Trochlear

Question 9

The key steps in secondary stroke prevention can be remembered by the mnemonic HALTSS:

Answer 9

HALTSS

Hypertension: studies show there is no benefit in lowering the blood pressure acutely (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure >180 mmHg). Anti-hypertensive therapy should, however, be initiated 2 weeks post-stroke.

Antiplatelet therapy: patients should be administered Clopidogrel 75 mg once daily for long-term antiplatelet therapy. In patients with ischaemic stroke secondary to atrial fibrillation, however, warfarin (target INR 2-3. or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke.

Lipid-lowering therapy: patients should be prescribed high dose atorvastatin 20-80 mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke).

Tobacco: offer smoking cessation support.

Sugar: patients should be screened for diabetes and managed appropriately.

**Surgery: ** patients with ipsilateral carotid artery stenosis more than 50% should be referred for carotid endarterectomy.

Rehabilitation and supportive management will include an MDT approach with involvement of physiotherapy, occupational therapy, speech and language therapy, and neurorehabiliation.