Geriatrics Flashcards
Delirium vs dementia
acute onset, impairment of consciousness, fluctuating sx (worse at night, periods of normality), abnormal perception (illusions, hallucinations), agitations, fear, delusions
Delirium RF
age>65yrs, BG dementia, significant injury (e.g. hip fracture), frailty, multimorbidity, polypharmacy.
Delirium precipitants:
infection (esp UTIs), metabolic (hyperCa, hypoglycaemia, hyperglycaemia, dehydration), change of environment, significant acute condition, severe pain, ETOH withdrawal, constipation
Delirium Rx
treat underlying, modify enviornment, haloperidol 0.5mg as sedative (contraix: in PD), in PD may need to carefully reduce PD meds (atypical antipsychotics preferred in PD - quetiapine, clozapine)
Alzheimer’s RF
age, Fhx, 5% aut dom mutations (in amyloid precursor protein (Chr21), presenilin 1 (Chr14), presenilin 2 (Chr1)), apoprotein E allele E4 (cholesterol transport protein), Caucasian ethnicity, Down’s
Pathology in Alzheimer’s
Macro: widespread cerebral atrophy, esp in cortex and hippocampus
Micro: cortical plaques due to type A-Beta-amyloid protein + intraneuronal neurofibrillary tangles deposition by abnormal aggregation of tau protein, hyperphosphorylation of the tau protein
Neurofibrillary tangles: paired helical filaments, partly made from tau proteins, which interact with tubulin to stablise microtubules and promote tubulin assembly into microtubules
Biochemical: Ach deficit due to ascending forebrain projection damage
Alzheimer’s Rx
non-pharmacological (activities, group cognitive stimulation therapy for mild-moderate, group reminiscence therapy + cognitive rehab). Pharmacological: Ach inhibitors (donepezil, galamantine, rivastigmine for mild-mod), memantine (NMDAr antagonist) 2nd line, if Ach inh contraix, add-on to Ach inh in mod-severe, monotherapy in severe.
Alzheimer’s classification
Mild: MMSE 21-26
Moderate: MMSE 10-20 (Mod-severe 10-14)
Severe: MMSE<10
Donepezil contraix
bradycardia
Donepezil SE
insomnia
Lewy body dementia
Pathology: alpha-synuclein cytoplasmic inclusions (Lewy bodies) in substantia nigra, paralimbic, neocortical areas
Sx: progressive cognitive impairment (pre-parkinsonism, but both within 1yr within each other), fluctuating cognition, early impairments in attention and executive function (more than just memory loss), parkinsonism, visual hallucination (+delusions)
Dx: clinical + SPECT (DaTscan, sensitivity 90%, specificity 100%)
Rx: Ach inhibitors, memantine. Avoid neuroleptics (can develop irreversible parkinsonism)
Frontotemporal lobar degeneration
3rd most common type of dementia, after Alzheimer’s and LBD. Sx: onset <65yrs, insidious, relatively preserved memory, visuospatial skills, personality change, social conduct issues
Frontotemporal dementia (pick’s disease): Sx: personality change, impaired social conduct, hyperorality, disinhibition, increased appetite, perseveration behaviours.
Pathology: focal gyral atrophy with a knife-blade appearance
Macro: frontal + temporal lobe atrophy
Micro: Pick bodies (spherical aggregations of tau protein (silver-staining), gliosis, neurofibrillary tangles, senile plaques.
Rx: no use for AChE inhibitors or memantine
Progressive non fluent aphasia (chronic progressive aphasia, CPA): non-fluent speech (short utterances, agrammatic), comprehension relatively preserved
Semantic dementia: fluent, progressive aphasia. Memory better for recent rather than remote events
Vascular dementia
Epidemiology: 2nd most common after A.D. 17% of dementia. Stroke doubles risk
Subtypes: stroke-related, subcortical (small vessel disease), mixed
RF: CVA, AF, HTN, DM, hyperlipideamia, smoking, obesity, IHD, FHx of CVA/IHD
Sx: stepwise deterioration, focal neuro, attention, concentration difficulty, seizures, memory, gait, speech, emotional disturbances
Dx: hx + exam, formal cognitive screen, medical r/v, MRI
NINDS-AIREN criteria: cognitive decline interfering with ADLs, not 2ndary to CVA effects + CVA + relationship between 2 (onset of dementia within 3 months post CVA, abrupt deterioration in cognitive functions, fluctuating, stepwise progression)
Rx: symptomatic, supportive, address CVS RF. Non-pharmacological Rx similar to AD
Pressure ulcers
RF: malnourishment, incontinence (urinary/faecal), immobility, pain
Waterlow score: includes BMI, nutritional status, skin type, mobility, continence
Grading:
1: non-blanchable erythema, intact skin. Discolouration, warmth, oedema, induration, hardness may also be present
2: partial thickness skin loss involving dermis/epidermis or both. Superficial ulcer, presents as abrasion or blister
3: full thickness skin loss with damage or necrosis of subcut tissue, may extend down to but not through underlying fascia
4: extensive destruction, necrosis, damage to muscle, bone or supporting structures with or without full thickness skin loss
Rx: moist wound environment with hydrocolloid dressings, hydrogels. Avoid soap. Only abx if evidence of cellulitis/infection. Referral to TVN. Surgical debridement if severe
