Geriatrics 2 Flashcards
When should anti-psychotics be avoided in patients with delirium?
Which medication would you use instead?
If the patient has a background of Parkinson’s disease.
Consider Lorazepam.
Why should anti-psychotics be avoided in patients with a background of Parkinson’s disease?
Anti-psychotics have strong anti-dopaminergic action, and as such, will make the patient’s condition significantly worse.
Describe the character of behavioural changes seen in Parkinson’s disease.
Chronic, progressive, and less labile in nature.
Which medications does NICE advocate the use of in a patient with delirium (and who does not have Parkinson’s disease)?
- Haloperidol
- Olanzapine
Which scoring system is useful in determining the risk of pressure sores?
Waterlow scale
Describe the categories of risk of pressure sores using the Waterlow Scale.
0 - 9 = Normal risk
10 - 14 = Increased risk
15 - 19 = High risk
20 - 64 = Very high risk
List some factors which are taken into account when assessing patients in light of the Waterlow Score*
- Waterlow score = assessment of risk of pressure sores
- Body habitus
- Continence status
- Malnutrition
- Mobility
- Neurological status
- Presence of trauma
Which patients develop pressure ulcers?
Patients who are unable to move parts of their body due to illness, paralysis or advancing age.
Where do pressure ulcers typically develop?
Over bony prominences such as the sacrum or hell.
Which 4 factors predispose a patient to developing pressure ulcers?
- Malnourishment
- Incontinence
- Lack of mobility
- Pain (leads to a reduction in mobility)
Describe a grade 1 pressure ulcer.
- Non-blanchable erythema of intact skin.
- Discolouration of skin, warmth, oedema, induration or hardness may be used as indicators, particularly on individuals with darker skin.
Describe a grade 2 pressure ulcer.
- Partial thickness skin loss involving epidermis or dermis, or both.
- The ulcer is superficial and presents clinically as an abrasion or blister.
Describe a grade 3 pressure ulcer.
- Full thickness skin loss involving damage to - or necrosis of - subcutaneous tissue that may extend down to, but not through, underlying fascia.
Describe a grade 4 pressure ulcer.
- Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with or without full thickness skin loss.
Describe the management of a pressure ulcer.
- Keep wound moist to encourage healing
- Avoid swabbing (most wounds are colonised with bacteria)
- Tissue Viability Nurse referral
- Surgical debridement may be beneficial for selected wounds.
A moist wound environment encourages ulcer healing. Which dressings should be used and should you use soap?
- Hydrocolloid dressings and hydrogels may help facilitate keeping the wound moist.
- The use of soap should be discouraged (to avoid drying the wound).
When might systemic antibiotics be prescribed in a patient with a pressure ulcer?
On a clinical basis eg. evidence of surrounding cellulitis.
What is the first line treatment for Vascular Dementia?
Tight control of vascular risk factors.
What is ‘vascular dementia?
A group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.
What %age of dementias in the UK are Vascular Dementia?
17%
What effect does a stroke have on the likelihood of developing vascular dementia?
- Stroke doubles the risk of developing dementia.
- Incidence increases with age.
What are the 3 main sub-types of vascular dementia?
- Stroke-related VD: multi-infarct or single-infarct dementia
- Subcortical VD: caused by small vessel disease
- Mixed dementia: the presence of both VD and Alzheimer’s disease
What are the risk factors for vascular dementia?
- Hx of Stroke / TIA
- AF
- HTN
- T2DM
- Hyperlipidaemia
- Smoking
- Obesity
- Coronary Heart Disease
- FHx Stroke / Cardiovascular disease
Rarely, Vascular Dementia can be inherited. Which condition is this associated with?
CADASIL
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy.
How does a patient with Vascular Dementia usually present?
Several months / years of sudden or STEPWISE DETERIORATION of cognitive function.
What symptoms might a person with Vascular Dementia exhibit?
- Focal neurological abnormalities eg. visual disturbance, sensory or motor symptoms
- Difficultly with attention and concentration
- Seizures
- Memory disturbance
- Gait disturbance
- Speech disturbance
- Emotional disturbance
What things are required to make a diagnosis of Vascular Dementia?
- Comprehensive Hx and Examination
- Formal screen for Cognitive Impairment
- Medical review to exclude medication cause of cognitive decline
- MRI scan: may show infarcts and extensive white matter changes.
Which criteria does NICE recommend using in people with probable Vascular Dementia?
NINDS-AIREN criteria
What does the NINDS-AIREN criteria (for diagnosing Vascular dementia) comprise?
1) Presence of cognitive decline that interferes with ADLs, not due to secondary effects of the cerebrovascular event
- > established using clinical examination and neuropsychological testing
2) Cerebrovascular disease
- > defined by neurological signs and/or brain imaging
3) A relationship between the above 2 disordered inferred by:
- the onset of dementia within 3 months following a recognised stroke
- an abrupt deterioration in cognitive functions
- fluctuating, stepwise progression of cognitive deficits.
Describe the general management of a patient with Vascular Dementia.
- Treatment is mainly symptomatic
- Manage cardiovascular risk factors -> this is important in slowing down disease progression.
Give some examples of non-pharmacological management of a patient with Vascular Dementia.
- Cognitive stimulation programmes
- Multisensory stimulation
- Music and art therapy
- Animal therapy
How might you manage ‘challenging behaviour’ (non-pharmacologically) exhibited by a patient with Vascular Dementia?
- Pain management!!!!!
- Avoid over crowding
- Clear communication
Describe the pharmacological management of a patient with Vascular Dementia.
- No specific approved treatment
- Consider AChE inhibitors if patient also has Alzheimer’s, Parkinson’s, or Dementia with Lewy Bodies.
What is the mechanism of action of Memantine?
NMDA antagonist
Haloperidol and Domperidone are both dopamine antagonists. Why can you use Domperidone but not Haloperidol in patients with Parkinson’s disease?
Haloperidol can worsen symptoms in those with Parkinson’s disease and should be avoided.
Domperidone does NOT easily cross the blood-brain-barrier and is actually considered safe for treating GI symptoms in patients with Parkinson’s disease, because the risk of developing extrapyramidal adverse effects is considered minimal.
List the anti-emetics which are safe to use in Parkinson’s disease.
- Domperidone
- Ondansetron
A patient presents with visual hallucinations and dementia. Which variety of dementia are they likely to be suffering from?
Lewy Body Dementia (LBD)
The visual hallucinations associated with LBD usually take the form of people or animals being in their presence.
Vascular dementia and CJD do not present characteristically with hallucinations.
What is Korsakoff syndrome?
- An amnesic disorder
- Caused by thiamine deficiency associated with prolonged ingestion of alcohol.
- Usually the result of untreated Wernicke’s encephalopathy.
What are the main symptoms of Korsakoff syndrome?
- Amnesia
- Confabulation
- Minimal content in conversation
- Lack of insight
- Apathy
- Usually the result of untreated Wernicke’s encephalopathy
What are some of the features of Wernicke’s encephalopathy?
- Confusion
- Altered conscious level
- Ataxia
- Ophthalmoplegia
Treatment: Thiamine
Why should you consider stopping tricyclic antidepressants in patients with Dementia?
Due to the risk of worsening cognitive impairment.
