Geriatrics Flashcards
Give the points of a Mini Mental State Exam
Orientation (time and place) - where they are, what date, time, month, year it is
Registration - 3 unrelated objects, get them to repeat
Attention and calculation - Do serial sum (keep subtracting 7 from 100), and/or spell word backwards
Recall - Say those 3 objects again
Language - Ask them to name an object, repeat phrase “no ifs, ands or buts”, give them a 3 stage command (take paper, fold it, throw it), read and do a command, writing a sentence, draw pentagons that intersect.
24-30 no impairment
18-23 mild
<18 severe impairment
What is osteoporosis
Low Bone Mineral Density (<2.5 SD from mean peak mass), causing fragile bones with increased risk of fracture
Risk factors for osteoporosis
SHATTERED
S - Steroid (glucocorticoids decrease Ca2+ absorption in gut)
H - Hyperthyroid, HyperPT, hypocalcaemia/Hypercalciuria
A - Alcohol/smoking
T - Thin (low BMI)
T - Testosterone decrease
E - Early menopause
R - Renal/liver failure
E - Erosive bone disease (myeloma, RA)
D - Dietary reduced Ca2+, malabsorption, diabetes
Also, older age, female, previous fragility fracture, physical inactivity
Conditions that cause secondary osteoporosis
- Hyperthyroid
- Hyperparathyroid
- Alcohol abuse
- Immobilisation
- Cushings
- Turner syndrome
What are the most common fractures in osteoporotic patients
- Vertebral crush
- Distal radius (Colles fracture) (wrist)
- Proximul femur/ NOF
In vertebral crush patient will have hunched back (kyphosis) and height loss >4cm.
Why does menopause cause osteoporosis
Oestrogen inhibits bone resorption by decreasing osteoclast activity. When this decreases (menopause) resorption>formation.
How is osteoporosis classified
Femoral neck T score, measured using a DEXA scan
Normal >-1
Osteopenia -2.5 to -1
Osteoporosis <-2.5
Severe <-2.5 and fracture
T score is SDs below average healthy adult
Investigations in osteoporosis
FRAX tool screening (Anyone on steroids, anyone over 50 with risk factors, women over 65, men over 75)
DEXA scan (Dual Energy Xray Absorptiometry) - measures bone mineral density. Usually measured at hip
Provides 2 readings;
- Z score - number of SDs patients BMD falls below mean for their age
- T score - number of SDs patients BMD falls below mean for young healthy adult
Ca2+, phosphate and ALP should all be tested (and appear normal unless underlying cause)
Management of osteoporosis
Lifestyle
- Activity/exercise
- Maintain weight
- Adequate vitD/calcium
- Stop smoking/alcohol.
Managed with bisphosphonates (Alendronate)
How should bisphosphonates be taken? What are their side effects?
To be given on empty stomach, first thing in the morning with a full glass of water. Stay upright for 30 mins after taking and dont eat or drink for 30 mins after.
- Reflux/oesophagitis
- Osteonecrosis of jaw
- Osteonecrosis of external auditory canal
- Oesophageal ulcers
How is osteoporosis monitored
Follow up in 5 years if no treatment
On treatment, FRAX/DEXA in 3-5 years. Come off treatment if BMD improves (T>-2.5) with no fragility fracture
Delirium vs Dementia
Factors pointing to delirium as opposed to dementia
- Acute onset
- Impairment of consciousness
- Fluctuating symptoms (worse at night/ periods of normality)
- Abnormal perceptions
- Agitiation, fear, delusions
What is Delirium
An acute, fluctuating disturbance of consciousness and cognition, often with altered attention and perception
Reversible, and has an acute cause
Causes of Delirium
PINCHME
Pain
Infection
Nutrition (electrolyte imbalances + hyponatraemia MC, also hypercalcaemia and hypo/hyperkalaemia)
Constipation
Hydration
Medication (opiates and anticholinergics)
Environment change
Risk factors for delirium
Age>65
Pre-existing cognitive development
Polypharmacy
Hospitalisation
Sensory impairment
Comorbidities
Clinical features of delirium
Types:
Hyperactive: Agitated, restless, hallucinating
Hypoactive: Lethargic, reduced responsiveness
Can be mixed
Symptoms:
- Acute onset, fluctuating course
- Impaired attention and concentration
- Disorientation/memory impairment
- Drowsiness, disorientation, disorganised thought
- Lack of interest
Possible investigations of delirium
Clinical diagnosis using DSM-5 and short Confusion Assessment Method (Short-CAM) but can diagnose cause
-Basic labs (FBC, U&E, thyroid, glucose, LFT)
- Infection screen: Urinalysis, blood culture, CXR
- Mediation review
- Calcium
- B12/folate
- CT head
Tests used to diagnose delirium
DSM-5
Short-CAM (confusion, inattention, disorganised thought, altered consciousness)
4As
- Alertness
- Attention (Test attention by asking them to list months of the year backwards)
- Acute change/fluctuation
- AMT4 (abbreviated mental test) (age, DOB, place, current year)
Risks of delirium left untreated
- Risk of dementia
- Longer hospital stay
- Increased mortality
What is benign paroxysmal position vertigo (BPPV)
Sudden onset dizziness and vertigo (false spinning/ moving sensation - self or world around you) triggered by changes in head position.
Average age of onset is 55 years. Good prognosis, resolves in weeks-months, half will have recurrence 3-5 years after diagnosis
Pathophysiology of benign paroxysmal position vertigo (BPPV)
Crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. Occurs most often in posterior semicircular canal.
May be displaced by viral infection, head trauma, ageing or without a known cause.
Crystals disrupt flow of endolymph, confusing the vestibular system. Head movement creates flow through canals, triggering vertigo
How does BPPV present and what examination can be done to confirm
- Vertigo triggered by a change in head position (could be rolling over in bed or looking up)
- Nausea
- 10-20 second episodes
Dix-Hallpike manoeuvre
- Patient sits with head turned to 45 and eyes wide open. Patient leans back to lying, with one ear pointed to the ground, let head go over the edge of the couch. (30-40 degrees).
- While in this position, check for nystagmus (involuntary eye movement) flickering towards affected side
- AKA Rotatory nystagmus, and repeat both sides
- (Triggers movement of endolymph through semicircular canals, triggering vertigo if they have BPPV)
How can BPPV be managed
Good prognosis, resolves spontaneously after weeks-months.
Epley manoeuvre (successful in 80% of cases)
- Follow steps of Dix Hallpike, until head turned 45, and dangling 30 off the edge of the bed
- Rotate 90 degrees past central position, and then have patient roll over, so head moves another 90 degrees.
- Have them sit up sideways off the edge of the couch and position head in central position (chin to chest).
- Support patients head for 30 seconds, until dizziness settles.
Can also teach exercises they can do alone (vestibular rehabilitation) - Brandt-Daroff exercises.
Betahistine can be used but “evidence limited” (so basically dont use but remember just in case for exam)
