Geriatrics

Question 1

Features acute confusional state (delirium)

Answer 1

• Memory disturbance
• Agitation or withdrawn
• Disorientation
• Mood change
• Visual hallucinations
• Disturbed sleep cycle
• Poor attention

Question 2

Management acute confusional state

Answer 2

Treatment of underlying cause
Modification of environment
Consider haloperidol or olanzapine

Question 3

Management acute confusional state in Parkinsons

Answer 3

Consider careful reduction of Parkinson medication
If symptoms require urgent treatment then atypical antipsychotics such as quetiapine and clozapine

Question 4

Non-pharmacological management Alzheimer’s

Answer 4

• Group cognitive stimulation therapy with mild and moderate dementia
• Group reminiscence therapy and cognitive rehabilitation

Question 5

First line pharmacological management Alzheimer’s disease

Answer 5

Acetylcholinesterase inhibitors:
- Donepezil
- Galantamine
- Rivastigmine

Question 6

Second line treatment Alzheimer’s disease

Answer 6

Memantine (NMDA receptor antagonist)

Question 7

When is memantine used

Answer 7

• Moderate Alzeimer’s who are intolerance of, or contraindication to, acetylcholinesterase inhibitors
• Add on drug to acetylcholinesterase inhibitors for patients with moderate-severe asthma
• Monotherapy in severe asthma

Question 8

Use of anti-psychotic medications in Alzheimer’s

Answer 8

Only used for patients at risk of harming themselves or others, or when agitation, hallucinations, or delusions causing severe depression

Question 9

CI’s donepezil

Answer 9

Bradycardia (relative)

Question 10

Adverse effects donepezil

Answer 10

Insomnia

Question 11

Dementia assessment tools in non-specialist setting recommended by NICE

Answer 11

10-point cognitive screener (10-CS)
6 item cognitive impairment test (6CIT)

Question 12

Investigation in primary care for suspected dementia

Answer 12

Blood screen to exclude reversible causes - FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12, folate

Question 13

Investigation in secondary care for suspected dementia

Answer 13

Neuroimaging to exclude reversible conditions, e.g. subdural haematoma, normal pressure hydrocephlaus

Question 14

Types of frontotemporal lobar degeneration

Answer 14

Frontotemporal dementia (Pick’s disease)
Progressive non-fluent aphasia
Semanic dementia

Question 15

Common features of frontotemporal lobar dementias

Answer 15

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

Question 16

Features frontotemporal dementia (Picks disease)

Answer 16

• Personality change
• Impaired social conduct
• Hyperorality
• Disinhibition
• Increased appetite
• Perseveration behaviours

Question 17

CT changes frontotemporal dementia

Answer 17

Focal gyral atrophy with knife-blade appearance

Question 18

Microscopic changes frontotemoral dementia

Answer 18

Pick bodies - spherical aggregations of tau protein
Gliosis
Neurofibrillary tangles
Senile plaques

Question 19

Features chronic progressive aphasia

Answer 19

Non fluent speech
Short utterances that are agrammatic
Comprehension relatively preserved

Question 20

Presentation semantic dementia

Answer 20

Fluent progressive aphasia - speech fluent but empty and conveys little meaning
Memory better for recent rather than remote events

Question 21

Macroscopic changes Alzheimers

Answer 21

Widespread cerebral atrophy, particularly involving cortex and hippocampus

Question 22

Microscopic changes Alzheimer’s

Answer 22

Cortical plaques due to deposition of type A-beta-amyloid protein and intraneuronal neurofibrillary tangles causes by abnormal aggregation of tau protein
Hyperphosphorylyation of tau protein

Question 23

Characteristic pathological feature of Lewy body dementia

Answer 23

Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic, and neocortical areas

Question 24

Features Lewy body dementia

Answer 24

Progressive cognitive impairment
Parkinsonism
Visual hallucinations

Question 25

Features of cognitive impairment in Lewy body dementia

Answer 25

Typically occurs before parkinsonism, but usually both features occur within a year of each other Congition may be flucutating Early impairments in attention and executive function rather than just memory loss

Question 26

Diagnosis Lewy body dementia

Answer 26

Usually clinical SPECT increasingly used

Question 27

Management Lewy body dementia

Answer 27

Acetylcholineterase inhibitors and memantine as in Alzheimer's

Question 28

Neuroleptics in Lewy body dementia

Answer 28

Should be avoided - patients extremely sensitive and may develop irreversible Parkinsonism

Question 29

What is vascular dementia

Answer 29

Group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease

Question 30

Presentation vascular dementia

Answer 30

Several months/years of history of sudden or stepwise deterioration of cognitive function Focal neurological abnormalities, e.g. visual disturbance, sensory or motor symptoms Difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance

Question 31

MRI findings vascular dementia

Answer 31

May show infarcts and extensive white matter changes

Question 32

Non-pharmacological management options in vascular dementia

Answer 32

Cognitive stimulation programmes Multisensory stimulation Music and art therapy Animal-assisted therapy

Question 33

Pharmacological management vascular dementia

Answer 33

Only consider AChE inhibitors or memantine if suspected comorbid forms of dementia that respond No evidence of effectiveness of aspirin or statins