Geriatrics Flashcards
Predisposing factors include:
of Delrium/ Acute confusional state
age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy
The precipitating events are often multifactorial and may include:
of Delirum
P
ain: Consider if the person is experiencing pain that could be contributing to delirium.
I
nfection: Look for signs of infection, such as fever, wound infection, or signs in urine or breath.
N
utrition: Evaluate the person’s nutritional status and whether they are eating well.
C
onstipation: Check for signs of constipation, which can be a cause of delirium.
H
ydration: Assess hydration status, looking for signs of dehydration, such as dark or smelly urine, dry lips/skin, or headache.
M
edication: Review the person’s medications and consider potential side effects or interactions.
E
nvironment: Consider the person’s environment, such as noise levels, temperature, and sensory overload.
metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
Delirum Managment after treatment of underlying cause, modification of environment
and if no Parkinsons D
and if PD
presenthaloperidol 0.5 mg may be used first-line
the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine
in patients with Parkinson’s disease, lorazepam is preferred if urgent treatment is required, or an atypical antipsychotic (e.g. quetiapine, clozapine) may be used
Pharmacological management
for Alzheimers D
IST line
the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease
Pharmacological management
for Alzheimers D
2nd line
memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used in the following situation reserved for patients with
moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
monotherapy in severe Alzheimer’s
When is Donepezil CI
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia
When can antipsychotics be used in Alzhemiers
antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
RF for Alzhemiers
increasing age
family history of Alzheimer’s disease
5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
apoprotein E allele E4 - encodes a cholesterol transport protein
Caucasian ethnicity
Down’s syndrome
Genetics in Alzheimers
5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
apoprotein E allele E4 - encodes a cholesterol
Pathological chnages in Alzeheuers
macroscopic
microscopic
biochemical
macroscopic:
widespread cerebral atrophy, particularly involving the cortex and hippocampus
microscopic:
cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
hyperphosphorylation of the tau protein has been linked to AD
biochemical
there is a deficit of acetylcholine from damage to an ascending forebrain projection
Factors favouring delirium over dementia
acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions
in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism)
which are
NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels
in secondary care, neuroimaging is performed* to exclude other reversible condition
(e.g. subdural haematoma, normal pressure hydrocephalus) and to help provide information on aetiology, guiding prognosis and management
according to the 2018 NICE guidelines, structural imaging should be offered to help exclude reversible causes of cognitive decline and to assist with subtype diagnosis unless dementia is well established and the subtype is clear
Common causes
Alzheimer’s disease
nd rare causes
HCPV
Common causes
Alzheimer’s disease
cerebrovascular disease: multi-infarct dementia (c. 10-20%)
Lewy body dementia (c. 10-20%)
Rarer causes (c. 5% of cases)
Huntington’s
CJD
Pick’s disease (atrophy of frontal and temporal lobes)
HIV (50% of AIDS patients)
There are three recognised types of FTLD
Frontotemporal lobar degeneration -Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer’s and Lewy body dementia.
There are three recognised types of FTLD
Frontotemporal dementia (Pick’s disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
Common features of frontotemporal lobar dementias
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
Mnagament of Picks disease
NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
one of the three FTLD
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
Semantic dementia
ONE OF THE 3 FTLD
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
Lewdy body dementia
The characteristic pathological feature is
The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
LBD and Parkinsons
what comes first
typically occurs before parkinsonism, but usually both features occur within a year of each other. This is in contrast to Parkinson’s disease, where the motor symptoms typically present at least one year before cognitive symptoms
LBD diagnosis
usually clinical
single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan
Mx LBD
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer’s
neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism.
The following factors predispose to the development of pressure ulcers:
malnourishment
incontinence: urinary and faecal
lack of mobility
pain (leads to a reduction in mobility)
screen for patients who are at risk of developing pressure areas
Waterlow score
Grade 1 Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2 Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister
Grade 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss
Mx of pressure ulcers
a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
consider referral to the tissue viability nurse
surgical debridement may be beneficial for selected wounds
Risk factors
for vascular dementia
History of stroke or transient ischaemic attack (TIA)
Atrial fibrillation
Hypertension
Diabetes mellitus
Hyperlipidaemia
Smoking
Obesity
Coronary heart disease
A family history of stroke or cardiovascular
