Geriatrics Flashcards
Which type of stroke is more common?
Ischaemic
What are the risk factors for strokes?
Same as CVD
- Age
- Male
- HTN/hyperlipidaemia
- Diabetes
- Smoking
- Previous TIA
- Heart disease/AF
- COC (ischaemic)
What are the clinical features of a stroke?
- Sudden limb/facial weakness
- Dysphasia
- Visual/sensory loss
- N+V
What are the investigations for haemorrhagic strokes?
- FIRST LINE = CT
- Diffusion-weighted MRI
What is the management for haemorrhagic strokes?
Acute:
- Neurosurgery - evacuate blood
- IV mannitol for high ICP
- Stop anticoagulants
Secondary:
- Anticoagulant
- BP aim of 140/90
- External ventricular drain (if hydrocephalus)
- Rehabilitation (SALT/PT/OT)
What type of infarcts occur in ischaemic strokes?
Cerebral:
- More common
- Occlusion of large blood vessel to cerebrum (e.g. internal carotid artery/middle cerebral artery)
Lacunar:
- Infarcts of smaller blood vessels
- Affected smaller areas e.g. internal capsule/basal ganglia/thalamus/pons
- Produce more specific symptoms
What are the investigations for ischaemic strokes?
- FIRST LINE = Bloods and CT (to rule out haemorrhagic)
- Diffusion-weighted MRI
- Carotid USS
What is the Bamford classification?
Categorises ischaemic strokes based on initial presenting features
- Total anterior circulation stroke
- Partial anterior circulation stroke
- Lacunar syndrome
- Posterior circulation syndrome
- Lateral medullary syndrome (Wallenberg’s syndrome)
- Weber’s syndrome
- Basilar artery
What is the Bamford classification criteria for total anterior circulation stroke?
ALL THREE:
- Unilateral weakness (and/or sensory deficit of face/arm/leg)
- Homonymous hemianopia
- Higher cerebral dysfunction (e.g. dysphasia/visuospatial disorder)
What is the Bamford classification criteria for partial anterior circulation stroke?
TWO:
- Unilateral weakness (and/or sensory deficit of face/arm/leg)
- Homonymous hemianopia
- Higher cerebral dysfunction (e.g. dysphasia/visuospatial disorder)
What is the Bamford classification criteria for lacunar syndrome?
ONE OF:
- Pure sensory stroke
- Pure motor stroke
- Sensorimotor stroke
- Ataxic hemiparesis
What is the Bamford classification criteria for posterior circulation syndrome?
ONE OF:
- CN palsy and a contralateral motor/sensory deficit
- Bilateral motor/sensory deficit
- Conjugate eye movement disorder (e.g. gaze palsy)
- Cerebral dysfunction (e.g. ataxia/nystagmus/vertigo)
- Isolated homonymous hemianopia/cortical blindness
What is the Bamford classification criteria for lateral medullary syndrome?
- Ipsilateral ataxia/nystagmus/dysphagia/facial numbness/CN palsy e.g. Horner’s syndrome
- Contralateral limb sensory loss
What is the Bamford classification criteria for Weber’s syndrome?
- Ipsilateral CN III palsy
- Contralateral weakness
What is the Bamford classification criteria for a basilar artery stroke?
‘Locked in’ syndrome
What is the management for ischaemic strokes?
Acute:
- Exclude haemorrhagic stroke (CT)
- Oral/rectal aspirin 300mg
- Thrombolysis = IV alteplase (within 4.5 hours of sx onset)
- Mechanical thrombectomy (within 6 hours)
- Aspirin 300mg daily for 2 weeks then clopidogrel
- Warfarin/apixaban
- Rehabilitation (SALT/OT/PT)
What is Wallenberg syndrome/lateral medullary syndrome?
Stroke due to blockage of posterior inferior cerebellar artery
- Causes ischaemia in lateral part of medulla oblongata in brainstem
- Involvement of lateral spinothalamic tract
- Ipsilateral facial pain and loss of temperature sensation
- Contralateral limb/torso pain and loss of temperature sensation
- Ataxia
- Nystagmus
What is lateral pontine syndrome?
Stroke due to blockage of anterior inferior cerebellar artery
- Artery supplies the pons
- Similar presentation to lateral medullary syndrome
- Ipsilateral facial paralysis
- Ipsilateral deafness
What are the clinical features of a stroke affecting the anterior cerebral artery?
- Contralateral hemiparesis and sensory deficits
- Lower extremities worse affected
What are the clinical features of a stroke affecting the middle cerebral artery?
- Contralateral hemiparesis
- Upper extremities worse affected
- Contralateral homonymous hemianopia
- Aphasia
What are the clinical features of a stroke affecting the posterior cerebral artery?
- Contralateral homonymous hemianopia with macular sparing
- Visual agnosia
What are the clinical features of a stroke affecting the retinal/ophthalmic artery?
Amaurosis fugax
What are the clinical features of a stroke affecting the basilar artery?
Locked-in syndrome
Describe lacunar strokes
- Strong association with HTN
- Common sites = basal ganglia/thalamus/internal capsule
- Isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
What are causes of transient ischaemic attacks?
- Thromboemboli
- Hypoviscosity
- Hypoperfusion
- Vasculitis
What is a crescendo TIA?
- 2 or more TIAs in 1 week
- High risk factor for stroke
What are the clinical features of a transient ischaemic attack?
- Last <24 hours without infarction (typically resolve within 10 minutes)
- Sudden facial/limb weakness
- Dysphasia
- Sensory/visual loss
- N+V
What are the investigations for transient ischaemic attacks?
- Blood glucose (hypoglycaemia can cause focal neurological symptoms)
- CT
- Diffusion-weighted MRI
- Carotid doppler
- ACBD2 risk score (age/BP/clinical features/duration/diabetes)
What is the management for transient ischaemic attacks?
- Aspirin (acute)
- Clopidogrel and atorvastatin (long term prophylaxis)
What are the most common types of dementia?
- Alzheimer’s
- Vascular
- Dementia with Lewy-body
- Frontotemporal dementia (a.k.a Pick’s disease)
Describe the pathophysiology of Alzheimer’s
- Mostly affects temporal lobes
- Senile plaques (deposits of beta-amyloid outside of neurons)
- Neurofibrillary tangles (aggregation of hyperphosphorylated tau proteins inside neurons which cause necrosis of neural tissue)
What are key clinical features of Alzheimer’s?
- Early impairment of memory
- Short-term memory loss/difficultly learning new information
- 4 A’s = amnesia, aphasia, agnosia, apraxia
What are investigations for Alzheimer’s?
- Cognitive assessment
- Memory assessment
- Bloods (TFTs/B12)
- CSF Tau studies
- CT/MRI
What is a common cognitive assessment?
AMT (abbreviated mental test):
1. Age
2. Time
3. Current year
4. Home address
5. Jobs of people asking questions (e.g. nurses/doctors)
6. DOB
7. Year WW1 started
8. Current monarch
9. Count backwards from 20
10. Repeat word mentioned earlier
<8 suggests cognitive impairment
What medications can be used for patients with dementia?
Mostly for Alzheimer’s:
- Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
- N-methyl-D-aspartic acid receptor antagonists (NMDA) e.g. memantine (for memory loss)
- Antipsychotics
What is the difference between dementia and delirium?
Dementia = slowly progressive changes with limited fluctuation. Attention is usually intact and very early memories may be preserved
Delirium = acute, transient and usually reversible changes. Often an associated acute illness
What are the most common causes of delirium?
PINCH ME:
- Pain
- Infection
- Nutrition
- Constipation
- Hydration
- Medication/metabolic
- Environment
What are the clinical features of delirium?
- Acute onset
- Fluctuating symptoms
- Disturbance in awareness and attention
- Disturbance in cognition
- Evidence of an organic cause
What are clinical features of hypoactive delirium?
- Lethargy
- Apathy
- Excessive sleeping
- Inattention
- Withdrawn
- Motor retardation
- Drowsy
- Unrousable
What are clinical features of hyperactive delirium?
- Agitation
- Aggression
- Restlessness
- Rapidly distracted
- Wandering
- Delusions
- Hallucinations
What are the investigations for delirium?
- Bloods (FBC/U&Es/TFTs/LFTs/B12 and folate/coagulation and INR/calcium/glucose/blood cultures)
- Urine dipstick
- MRI/CT
- CXR
What criteria is used for delirium?
DSM-5 criteria:
- Disturbance in awareness
- Acute onset
- Disturbance in cognition
- Not better explained by a pre-existing established or evolving neurocognitive disorder
- Absence of severely reduced GCS
- Evidence of organic cause
What is the management for delirium?
- Determine/treat underlying cause
- Rapid tranquilisation (benzodiazepines e.g. lorazepam/antipsychotics e.g. haloperidol, olanzapine)
- De-escalation methods (maintain adequate distance/move to safe, low-stimulant environment/use non-threatening verbal and non-verbal techniques/involve relatives or people close to patient)
Describe the pathophysiology of vascular dementia
- Subcortical VD (disease affected small vessels of brain)
- Stroke-related VD (following large cortical stroke)
- Single/multi-infarct VD (following single/multiple small strokes)
Describe the pathophysiology of Lewy-Body dementia
- If dementia symptoms 12 months before motor symptoms
- Histopathological findings of intracytoplasmic inclusions (Lewy bodies) that contain alpha-synuclein
- Lewy bodies lead to reduced levels of acetylcholine and dopamine in the brain
Describe the pathophysiology of frontotemporal dementia
- Tissue deposition of aggregated proteins (phosphorylated tau or transactive response DNA-binding protein 43)
- Atrophy around frontal/temporal lobes
What are general clinical features of dementia?
- Slow onset sx
- Lack of insight
- Cognitive impairment
- Behavioural and psychological sx
- Decreased ability to carry out ADLs
What are key clinical features of vascular dementia?
- Stepwise decline in function
- Gait/attention/personality changes
- Focal neurological symptoms e.g. aphasia/weakness
What are key clinical features of Lewy-Body dementia?
- Fluctuating cognitive impairment
- Parkinsonism sx (tremor/rigidity/bradykinesia/postural instability)
- Falls/syncope/hallucinations
- Sleep disturbances/restlessness at night
What are key clinical features of frontotemporal dementia?
- Personality changes and behavioural disturbances (disinhibition)
- Memory and perception relatively preserved
- Stereotypical, repetitive, compulsive behaviour/emotional blunting/abnormal eating/language problems
What is sundowning?
Increase in certain symptoms (e.g. distress/agitation/hallucinations/delusions) in dementia patients that often occur in the late afternoon/evening
What are investigations for dementia?
- Exclude alternative diagnoses
- Cognitive assessments
- Bloods
- ECG
- Virology
- Syphilis testing
- CXR
- CT/MRI head
What are some differential diagnoses for dementia?
- Depression
- Drugs with anticholinergic effects
- Delirium
What is the management for dementia?
- Assess capacity
- Inform DVLA
- Cognitive stimulation therapy
- Cognitive rehabilitation
- Reminiscence work
- Admiral nurses
- Reduce risk factors (e.g. for VD) - stop smoking/exercise/statins/etc.
- Medications
What are risk factors for Parkinson’s?
- Age
- Male
- Pesticide exposure
Describe the pathophysiology of Parkinson’s
- Basal ganglia responsible for coordinating habitual movements
- Substantia nigra = part of basal ganglia that produce dopamine (needed for functioning of basal ganglia)
- Parkinson’s = gradual fall in production of dopamine
What are the clinical features of Parkinson’s?
- Unilateral symptoms (bilateral suggests drug-induced)
- Resting ‘pill rolling’ tremor better on voluntary movement
- Cogwheel rigidity
- Bradykinesia (shuffling gait/small handwriting/hypomimia)
What investigation can differentiate Parkinson’s Disease and benign essential tremor?
DAT scan:
- Normal in tremor
What is the management for Parkinson’s?
- FIRST LINE = Levodopa + peripheral decarboxylase inhibitors (Carbidopa/benserazide)
- Catechol-o-methyltransferase (COMT) inhibitors e.g. entacapone
- Dopamine agonists e.g. bromocriptine/cabergoline/pergolide
- Monoamine oxidase-B inhibitors e.g. selegiline/rasagiline
What are the side effects of excess dopamine?
- Dyskinesias (dystonia/chorea/athetosis)
- Treat with amantadine (glutamate antagonist)
What is benign paroxysmal positional vertigo and what are some causes?
Sudden onset of dizziness and vertigo triggered by changes in head position
- Caused by displacement of otoconia due to infection/trauma/ageing
Describe the pathophysiology of benign paroxysmal positional vertigo
- Crystals of calcium carbonate (otoconia) become displaced in semi-circular canals (most often posterior)
- Crystals disrupt normal flow of endolymph through canals
- Head movements creates the flow of endolymph in the canals, triggering vertigo
What are the clinical features of benign paroxysmal positional vertigo?
- Triggered by head movements e.g. turning over in bed
- Vertigo
- Sx settle after around 20-60 seconds
- Asx between attacks
- NO hearing loss/tinnitus
What is the investigation for benign paroxysmal positional vertigo
Dix-Hallpike manoeuvre:
- Sit patient upright with head turned 45 degrees to one side
- Support patient’s head to stay in 45 degree position whilst lowering patient backwards until head is hanging off end of bed, extended 20-30 degrees
- Hold patient’s head still
- Watch eyes
- Positive = rotational nystagmus and symptoms of vertigo
What is the management for benign paroxysmal positional vertigo
- Epley manoeuvre
- Daroff exercises
What are causes of falls in the elderly?
I HATE FALLING:
- Inflammation
- Hypotension
- Arrhythmia
- Tremor
- Equilibrium (balance issues - drug induced/other)
- Foot pain
- Auditory/visual impairment
- Leg length discrepancy
- Lack of conditioning
- Illness
- Nutrition poor
- Gait problems
What are the investigations for falls in the elderly?
- Bloods
- CT
- ECG
- Medication review
- PRISMA-7 (frailty assessment questionnaire)
What medications can increase the likelihood of falls in the elderly?
- Beta blockers (bradycardia)
- Diabetic medications (hypoglycaemia)
- Antihypertensives (hypotension)
- Benzodiazepines (sedation)
- Abx (intercurrent infection)
What is the management for falls?
- Stop medications that can cause falls
- Footwear/walking aid
- Fludrocortisone (if postural hypotension)
- PT/OT/ACP/care home
What is the PRISMA-7 questionnaire?
Frailty assessment questionnaire:
- >85 years
- Male
- Any health problems that require you to limit activities
- Need someone to help you on a regular basis
- Any health problems that require you to stay at home
- Can you count on someone close to you to help
- Do you regularly use a stick/walker/wheelchair
How else can frailty be assessed?
Rockwood clinical frailty scale:
- 1 = very fit
- 2 = well
- 3 = managing well
- 4 = vulnerable
- 5 = mildly frail
- 6 = moderately frail
- 7 = severely frail
- 8 = very severely frail
- 9 = terminally ill
What are risk factors for osteoporosis?
- Older age
- Female
- Low mobility/activity
- Low BMI (<19)
- Low calcium/vitamin D intake
- Alcohol/smoking
- Personal/family history of fractures
- Chronic diseases e.g. RA/CKD/hyperthyroidism
- Long term corticosteroids
- Certain medications e.g. SSRIs/PPIs/anti-epileptics/anti-oestrogens
What are the investigations for osteoporosis?
- DEXA (dual energy x-ray absorptiometry) scan = T-score and Z-score of femoral neck
- Qfracture tool/FRAX = 10 year risk of major osteoporotic fracture and hip fracture
Describe the results of a T-score
Number of standard deviations away from average healthy young adult
- Normal = >-1
- Osteopenia = -1 to -2.5
- Osteoporosis = <-2.5
What is the management for osteoporosis?
- Calcichew + bisphosphonates (e.g. alendronate/risedronate/zoledronic acid)
- HRT
- Denosumab
- Raloxifene
- Strontium ranelate
- Ranelate
How should bisphosphonates be taken?
Taken on an empty stomach with a full glass of water and afterwards, patient should sit upright for 30 minutes before moving or eating to reduce risk of reflux and oesophageal erosions
What are side effects of bisphosphonates?
- Reflux and oesophageal erosions
- Atypical fractures
- Osteonecrosis of jaw
- Osteonecrosis of external auditory canal
What are side effects of raloxifene?
- Stimulates oestrogen receptors in bone but not in uterus or breast
- Increases risk of VTE
What are side effects of strontium ranelate?
Increases risk of VTE and MI
What are causes of constipation?
- Dietary (inadequate fluid/fibre)
- Behavioural (inactivity/avoidance)
- Electrolyte disturbance (hypercalcaemia)
- Drugs (opiates/CCBs/antipsychotics)
- Neurological disorders (spinal cord lesions/Parkinson’s/diabetic neuropathy)
- Endocrine disorders (hypothyroidism)
- Colon disease (stricture/malignancy)
- Anal disease (fissue/proctitis)
What criteria is used for constipation?
ROME IV criteria:
- Infrequent bowel motions (<3 per week)
- Hard stool in >25% of BMs
- Tenesmus in >25% of BMs
- Excessive straining in >25% of BMs
- A need for digital evacuation of BMs
What are clinical features of constipation?
- Difficulty passing BMs
- Abdominal distension
- Abdominal mass
- Rectal bleeding
- Anal fissures
- Haemorrhoids
- Presence of hard stool/impaction on DRE
What are the investigations for constipation?
- Bristol stool chart
- Bloods
- Abdominal x-ray
- Barium enema
- Colonoscopy
What is the management for constipation?
- Bulk laxatives e.g. ispaghula husk/methylcellulose
- Stool softeners e.g. docusate sodium
- Osmotic laxatives e.g. lactulose/macrogol
- Stimulant laxatives e.g. senna/bisacodyl
What are the main types of urinary incontinence?
- Urge = overactivity of detrusor muscle
- Stress = weakness of pelvic floor/sphincter muscles
- Overflow = chronic urinary retention due to outflow obstruction
What are age-related causes of urinary incontinence?
- Reduced total bladder capacity
- Reduced bladder contractile function
- Reduced ability to postpone voiding
- Atrophy of vagina/urethra
- Loss of pelvic floor/urethral sphincter musculature
- Hypertrophy of prostate
- Comorbidity (reduced mobility/medication/constipation/impaired cognition)
What are the investigations for urinary incontinence?
- Bladder diary
- Vaginal/rectal/neuro examination
- Urinalysis/MSU
What is the management for urge incontinence?
- Bladder retraining
- Anticholinergic medication e.g. oxybutynin/tolterodine/solifenacin
- Mirabegron
- Botox in bladder wall
What is the management for stress incontinence?
- Avoid caffeine/diuretics
- Avoid excessive/restricted fluid intake
- Weight loss
- Pelvic floor exercises
- Sling procedure
- Duloxetine
- Finasteride/tamsulosin (if BPH)
What are the main causes of malnutrition?
- Decreased nutrient intake (starvation)
- Increased nutrient requirements (sepsis/injury)
- Inability to utilise ingested nutrients (malabsorption)
What are the clinical features of malnutrition?
- Low skeletal muscle mass
- Depleted subcutaneous fat stores
- High susceptibility/long duration of infections
- Slow/poor wound healing
- Altered vital signs (bradycardia/hypotension/hypothermia)
What is the investigation for malnutrition?
MUST score
- BMI (>20/18.5-20/<20 = 0/1/2)
- Unplanned weight loss in past 3-6 months (<5%/5-10%/>10% = 0/1/2)
- Acute disease with no nutritional intake for >5 days (2)
- = low/medium/high risk (0/1/2+)
What is the management for malnutrition?
- Treat cause
- Dietician
- Oral nutrition
- Gastrostomy (PEG/RIG) or jejunostomy
- Parenteral nutrition
What are the MUST guidelines for malnutrition?
- Low risk = routine clinical care, repeat screening weekly/monthly/annually
- Medium risk = document dietary intake for 3 days; if adequate repeat screening; if not, set goals, improve/increase nutritional intake, monitor/review care plan
- High risk = refer to dietician/nutritional support team, set goals, improve/increase nutritional intake, monitor/review care plan
What is a complication of treating malnutrition?
Refeeding syndrome - metabolic disturbances as a result of reintroduction of nutrition to patients who are already starved/severely malnourished
What are the clinical features of refeeding syndrome?
- Hypophosphatemia
- Hypokalaemia
- Thiamine deficiency
- Abnormal glucose metabolism
What is the management for refeeding syndrome?
- Monitor blood biochemistry
- Commence refeeding with guidelines
- Recognise electrolytes (phosphate/K+/Mg)
- Monitor glucose/Na levels
- Supportive care
What are the complications of refeeding syndrome?
- Arrhythmias
- Coma
- Convulsions
- Cardiac failure
What components are required for someone to be deemed to have capacity?
- Understand information
- Retain information
- Weigh up information
- Communicate decision
What are some legal actions that are more relevant to geriatrics?
- Deprivation of liberty safeguards (DoLS)
- Lasting power of attorney
- Independent mental capacity advocate
- Mental capacity act
- Advanced directives
What is required to make a advanced directive legally binding?
- Patient is an adult
- Was competent and fully informed when making the decision
- Decision is clearly applicable to current circumstances
- There is no reason to believe that they have since changed their mind
What are the most common causes of adverse drug reaction related admissions?
- NSAIDs
- Diuretics
- Warfarin
- ACEIs/AIIRAs
- Antidepressants
- Beta blockers
- Opiates
- Digoxin
- Prednisolone
- Clopidogrel
What tools are used in polypharmacy?
- START tool = Screening Tool to Alert to Right Treatment
- STOPP tool = Screening Tool of Older People’s Prescriptions
What is an example of the STOPP tool?
Medications such as TCAs (amitriptyline) should be stopped in patients with dementia due to risk of worsening cognitive impairment
What are the main risk factors for pressure sores?
- Malnourishment
- Incontinence
- Lack of mobility
- Pain
Describe the pathophysiology of pressure sores
- Prolonged pressure on particular area causes skin breakdown
- Due to combination of reduced blood supply and localised ischaemia, reduced lymph drainage and a deformation of the tissue under pressure
What are the clinical features of pressure sores?
- Discoloured non-blanching patches of skin
- Patch of skin that feels warm/spongy/hard
- Pain/itchiness in affected area
- Blister/open wound
- Exposed layers of skin/muscle/bone
What are the investigations for pressure sores?
- Waterlow score = assess risk
Classification:
- Grade 1 = non-blanching erythema with intact skin
- Grade 2 = partial thickness skin loss involving epidermis, dermis or both (abrasion/blister)
- Grade 3 = full thickness skin loss involving damage/necrosis of subcutaneous tissue
- Grade 4 = extensive loss, destruction/necrosis of muscle, bone or support structures
What is the management for pressure sores?
- Moist wound environment = hydrocolloid dressings and hydrogels
- Surgical debridement
- Abx (only if signs of infection)
What are preventative measures for pressure sores?
- Barrier creams
- Pressure redistribution
- Repositioning
- Regular skin assessment
How is lying/standing BP measured?
- BP after 5 mins of lying down
- BP after 1 min of standing
- BP after 3 mins of standing
What is the criteria for a diagnosis of orthostatic/postural hypotension?
- Systolic drops >20mmHg
- Systolic drop to below 90mmHg
- Diastolic drop >10mmHg + symptoms
What is the management for orthostatic/postural hypotension?
- Compression stockings
- Fludrocortisone
What is compartment syndrome and what are the main causes?
Post fracture - raised pressure within close anatomical space which compromises tissue perfusion and leads to necrosis
- Supracondylar fractures
- Tibial shaft injuries
What are the clinical features of compartment syndrome?
- Pain (especially on movement)
- Paraesthesia
- Pallor
- Pulses may be weak
- Paralysis of muscle group may occur
What is the investigation and management for compartment syndrome?
- Intracompartmental manometry (>40+mmHg)
- Fasciotomy
