Geriatrics Flashcards
Hutchinson- Gilford syndrome
Type of inheritence
Premature ageing onset in childhood (hatching soon or hutchin son)
Autosomal dominant
Mutation in lamin A protein that normally keeps nuclear envelope stable, so leads to nucleus damage making cells more likely to die prematurely
What is Werner’s syndrome?
Type of inheritance?
Premature ageing that onsets in adulthood.
Autosomal recessive mutation in a DNA helicase on chromosome 8
4 As of Alzeihmers
Amnesia
Aphasia- difficulty speaking
Agnosia- can’t name things
Apraxia- difficulty doing mechanical tasks
What deficit in cognition occurs in depression? How would this appear on cognitive tests?
Poor attention and concentration
Can’t spell WORLD backwards, serial 7s
intact orientation
Why give donepezil over rivastigmine for people with Parkinsons?
Donepezil (anticholinesterase) comes as a patch rather than a pill so good when patients get swallowing difficulties
What drugs cause delirium in the elderly?
ABCCD
Analgesics- opioids, NSAIDs Benzodiazepine withdrawal Anti-Cholinergics (TCAs worse than tioptropium) Corticosteroids Dopaminergics (Parkinson's)
Lithium
Metabolic causes of delirium?
Low Na+
Low glucose
High calcium
High urea- kidney failure
What are the indications for an urgent CT scan in an elderly person with confusion?
Headache
Decreased GCS or fluctuating (may suggest subdural bleed)
Focal neurological signs
Which drugs should be avoided in Parkinson’s patients?
Haloperidol
Metoclopramide- for nausea
(Dopamine antagonist)
AMTS?
6 numbers: Age DOB Time Current Year WW2 Year 20 to 1
2 Place:
Where are you
Address to remember
2 Naming:
Who are 2 professionals
Who is current prime minister
What are the different types of medication for osteoporosis?
BS-DT: bullsh* design tech
Bisphosphonates- alendronate (inhibit osteoclasts)
Selective Estrogen Receptor Modulator- tamoxifen (inhibits osteoclast differentiation and induces apoptosis)
Denosumab- Monoclonal Ab against RANK on osteoclasts (osteoblasts contain a complimentary Rank-ligand that activates)
Teriparatide- recombinant PTH, intermittent PTH stimulates osteoblasts more than osteoclasts
Why does Terapartide (recombinant PTH) work to increase bone density when chronically high PTH leads to bone break down?
Intermittent PTH stimulates osteoblasts more than osteoclasts leading to bone being built up.
Constant PTH leads to osteoclast activation and bone break down.
Which medications are risk factors for falling?
AABCDDS
Antidepressants, antipsychotics
Benzodiazepines- cognition, balance, gait
Class 1a anti-arrhythmias (Na Ch blockers, precipitate heart block- procainamide)
Digoxin- haemodynamic changes
Diuretics- lowered BP
Sedatives
If making decisions with the patients best interests, who has no family, who should be included in the process?
Look for advanced decision
Assign Independent Mental Capacity Advocate
If urgent, don’t need to wait for IMPCA but may consult afterwards
What is the physiology of paroxysmal nocturnal dyspnoea?
Whilst laying down, with reduced sensory awareness in sleep, L heart failure leads to pulmonary oedema = gasping for breath as they wake up
In spirometry, in a patient with a restrictive lung disease which lung function value is reduced?
Full vital capacity FVC
Ie in fibrosis, lack of elasticity prevents expansion of lungs.
In lung function tests, what happens to the residual capacity in a patient with asthma or COPD?
Residual capacity increases as not all the air can be expired before small airways are compressed by thoracic pressure
What causes bronchial breathing?
Harsh sounds due to firm/solid lung tissue:
Consolidation
Fibrosis
Pleural/pericardial effusion
What causes diminished breath sounds?
Reduced transmission:
Pleural effusion
pleural thickening
Reduced air entry:
Pneumothorax
Asthma, COPD
What causes monophonic and polyphonic wheeze?
Due to turbulent air flow as it's expired through narrow airways: Monophonic- one airway, a tumour Polyphonic- multiple airways: asthma, COPD L ventricular failure
What causes crackles/crepitations?
Coarse Vs Fine?
Re-opening of small airways during inspiration, that were occluded from expiration.
Coarse = small airways, bronchiectasis, COPD Fine = alveoli + interstitium, pulmonary oedema, fibrosis
Cause of coarse crackles?
Small airways opening up:
Bronchiectasis, COPD
Cause of fine crackles?
Alveoli and interstitium opening up:
Pulmonary oedema, fibrosis
Causes of a pleural rub?
Movement of visceral pleura over parietal pleura when roughened by inflammation:
Pneumonia
Pulmonary infarction
How does vocal resonance change in the resp exam with consolidation?
Increases due to improved transmission
Which cell types don’t divide and need to last a lifetime?
Neurones
Renal cells
Myocardium
What medication is licensed for treating restless legs (that prevents sleep) in the elderly?
Dopamine agonists:
Pramipexole
Ripinirole
Which drugs can cause sleep disturbance? (Particularly in the elderly)
All things used in asthma:
Theophylline (bronchodilator in asthma, TNF-i reduce inflammation)
Sympathomimetics
High dose steroids
Rx of delirium tremens in alcohol withdrawal?
Mechanism of action?
Who should not receive this?
Chlordiazepoxide
Facilitates inhibitory GABA binding to GABA-A receptors
Easily crosses placenta, not for pregnant/breastfeeding women
What is the differential of dementia?
Acute confusional state Depression (pseudo) Communication difficulties- deafness, poor vision, language deficits Parkinson's Schizophrenia, mania
You notice Parkinsonian features in a patient with cognitive decline? Which type of dementia’s are more likely?
Lewy body dementia
Vascular dementia
Blood tests to exclude other causes in suspected dementia?
FBC- macrocytic anaemia in alcoholism Biochemistry- severe hypoglycaemia ESR- syphilis/HIV Thyroid function B12+ folate
If at risk:
Syphilis serology
HIV test
Investigations (not bloods) useful to exclude other causes in dementia?
CT/MRI- exclude tumour, determine if vascular disease
CXR- delirium causes ie infection
ECG- delirium cause ie MI
Difference between vitamin B12 and B1 deficiencies?
Both occur in alcoholics.
B12: peripheral neuropathy and depression/psychosis/dementia
Macrocytic anaemia, glossitis, subacute degeneration of the cord (ataxia from loss of proprioception).
Rx: B12 (hydroxycobalamin) then folate.
B1 (Thiamine): Beriberi -HF
Wernicke’s- confusion, ataxia, opthalmoplegia
Korsakoff’s- amnesia, can’t make memories
Rx: Pabrinex, B1 then glucose.
What is the pathophysiology of Alzeihmers disease?
Amyloid precursor protein (chromosome 21) is cleaved by:
beta + gamma secretase to form
AMYLOID beta (40 or 42 forms)
Build up of AB (particularly AB-42) leads to plaques and neuronal death.
Tau- intracellular microtubule assembly protein forms aggregates = toxic
Why are Down’s patients more at risk of Alzeihmers?
Amyloid precursor protein is on chromosome 21
So they get more build up of amyloid-beta
What is the link between insulin sensitivity and Alzeihmers?
Amyloid-beta competes with insulin for insulin-R’s leading to abnormal glucose metabolism in neurones
Why are anti-cholinesterases used in Alzeihmers?
Examples of drugs?
Predominantly cholinergic neurones are destroyed in Alzeihmers so anticholinesterases boost ACh levels.
Donezepil, Galantamine, Rivastigmine (non-competitive)
What are NICE guidelines on when to start and stop prescribing AChE-inhibitors in Alzeihmers?
MMSE above 10 (mild or moderate)
Continue drug if cognitive/behavioural benefit
Stop if MMSE falls below 10 or no benefit
Which co-morbidities in Alzeihmer’s patients would you need to be careful of, when prescribing AChE-inhibitors like Donezepil?
If increased parasympathetic input would be problematic:
Sick sinus syndrome
Peptic ulcer -M3 R = stomach acid secretion
COPD -M R = bronchoconstriction
Urinary retention
Patient has been having memory problems and hallucinations/delusions. What type of dementia is most likely? What other features are characteristic?
Lewy-body dementia (misfolded alpha-synuclein deposits)
Postural instability, severe ‘sundowning’
How do you define whether a patient has Lewy body dementia or Parkinson’s?
If cognitive symptoms precede movement symptoms by 1 year = Lewy Body dementia
What characterises fronto-temporal dementia?
What differences occur if it is predominantly right sided or left sided?
Change in personality, social behaviour, language ability
More preserved orientation and memory than Alzeihmers
Right- behaviour
Left- language
Pathological process causing frontotemporal dementia?
Intracellular microtubule assembly protein Tau accumulation.
You are considering a patient with dementia who has recently moved to the UK from Mexico, his MRI shows a number of cysts. What could be the rare cause?
CNS cysticercosis- due to Taenia solium (pork tapeworm)
Diagnose via serology tests, stool microscopy of perianal swabs
Rx: Praziquantel, albendazole
Patient has an apraxic gait, dementia and incontinence.
What could be the rare cause?
Investigation?
Normal pressure hydrocephalus
CT head
Rx: CSF shunt drainage
Patient with dementia, opthalmoplegia and myoclonus. No alcohol history (it’s not Wernicke’s).
Also fever, weight loss and diarrhoea
Diagnosis?
Whipple’s disease
Tropheryma whippelii leads to GI malabsorption
= arthralgia, diarrhoea, lymphadenopathy, endocarditis
Rx: ceftriaxone
Diarrhoea, Dementia and Dermatitis
Are the triad of what?
Rx?
Pellagra- lack of nicotinic acid
Endemic in China and Africa
Rx: nicotinamide
Palsy of which nerve is associated with a high-stepping gait (due to foot-drop)?
Common peroneal nerve
What symptoms to ask when taking a history of a fall?
dizziness, light-headed
chest pain, palpitations
loss of consciousness, weakness
prodrome
PMH: peripheral neuropathy, dementia, strokes, MIs, epilepsy
DHx: antihypertensives, sedatives, antipsychotics etc
Common causes of muscle pain/stiffness in the elderly?
MP for muscle pain
Myositis (viral, inclusion body, autoimmune)
Polymyalgia rheumatica (give prednisolone)
Myxoedema, hypothyroidism
Parkinson’s disease
What causes pathological fractures from falls in elderly men?
Idiopathic osteoporosis
Malabsorption- Crohns, gastric surgery, coeliac Alcohol Steroids Hyperparathyroidism Hypogonadotrophic hypogonadism
A patient has a fall and when her height is measured she is 4cm shorter than before. What may have happened?
Multiple vertebral fractures.
Should have kyphosis of spine too
What is the difference between a T score and a Z score with a DEXA scan?
T score compares density to a pre-menopausal woman
Z score compares density to age-matched controls
Blood tests to exclude secondary osteoporosis?
TFT: thyrotoxicosis
Testosterone: hypogonadotrophic hypogonadism
ESR + Ig: myeloma
Dexamethosone supression test: Cushing’s (cortisol)
What precautions need to be taken when administering bisphosphonates (for osteoporosis)?
Take on an empty stomach- absorption
Remain upright for 30 minutes- reduce oesophageal ulceration
For pain relief in those with osteoporotic bone pain what may be used?
Calcitonin- acts kind of oppositely to PTH
Inhibits osteoclasts, stimulates osteoblasts etc
What is osteomalacia?
Reduced calcification of the osteoid matrix due to vitamin D deficiency = soft and weak bone
(Rickets for adults)
Which drugs may cause osteomalacia?
Those that induce liver enzymes, increasing vit D clearance:
Antiepileptics:
Phenytoin
Carbemazepine
What blood test findings are associated with osteomalacia?
Alk phosphatase is a byproduct of bone turnover
Turnover is increased because:
Low vit D = low Ca absorption in gut = low Ca = ^ PTH
What is Paget’s disease?
Increased activity of osteoblasts and osteoclasts leads to more bone turnover. Whilst there is more bone, it is weaker than normal bone due to abnormal architecture.
How do osteomalacia and paget’s disease look different on xray?
Osteomalacia (lack of vit D) = loss of cortical bone, Looser’s zones of transverse lucencies.
Paget’s (increased turnover) = patchy cortical thickening, enlarged bones, sclerosis + osteolysis
What analgesia is most effective for Paget’s disease bone pain?
Alendronate (bisphosphonate inhibiting osteoclasts)
With paget’s and osteomalacia how to do calcium, phosphate and alk phos levels differ?
Both have increased alk phos due to bone turnover
Osteomalacia from ^ PTH from low Ca.
Osteomalacia low Ca due to low Vit D
Paget’s high Ca (in immobile patients) due to breakdown
Osteoarthritis Rx?
1st: paracetamol ± topical NSAID
2nd: + oral NSAID
Alongside: capsaicin, intra-articular steroid injection (lasts 2 weeks)
Difference between gout and pseudogout?
Gout-urate (negatively birefringent)
Pseudogout- pyrophosphate (positively birefringent)
Gout- MTP of big toe, ankle, PIP joints of fingers
Pesudogout- large joints like knee
Rx for long term prevention of gout?
Allopurinol
Don’t use it soon after acute attack as may precipitate another
Which virus has been linked to Paget’s disease?
Parvovirus
Features of polymyalgia rheumatica?
Which blood test
3 of:
Bilateral shoulder pain + neck stiffness
Bilateral tenderness in upper arms
Morning stiffness lasting 1 hour +
Illness onset in last 2 weeks
Age over 65
Depression/weight loss
ESR more than 40
If patient is nearing end of life and has difficulty breathing due to bubbly secretions, what can you give her?
Hyosine hydrobromide
Patient is taking Amlodipine, Ramipril, Metformin, Warfarin, Omprazole, Salbutamol and gets dehydrated, with a history of renal impairment, what changes should be made?
Stop metformin (lactic acidosis) and ACEi- prevents constriction of efferent arteriole that maintains glomerular perfusion pressure when the kidney is already hypoperfused
For a patient lying on the floor for a long time, what should you check to see if they are having rhabdomyolysis?
Creatinine Kinase
What is the danger of giving nitrofurantoin in the elderly for a simple UTI
Is renally cleared so can accumulate with AKI
Patient takes antihypertensives and gets sepsis, what should you do?
If BP is low, stop antihypertensives
Mode of clearance by gentamycin- kidney or liver?
Kidney
Hence first dose may be okay, second dose might not be
Which antibiotic should be avoided if patient is taking Warfarin?
Ciprofloxacin and macrolides
CytP-450 inhibitors so warfarin conc gets higher
What is the danger of low potassium in a patient taking digoxin?
Digoxin toxicity- related to competition for the sodium/potassium pump. in the heart, digoxin is already causing reduction in K/Na/ATPase pump activity
Which painkiller should you be careful of in renal failure?
Give lower morphine dose as it’s renally cleared (maybe).
What neurological impact can drinking alot of alcohol have?
Peripheral neuropathy
Cerebellar degeneration
Vitamin-related deficiencys
What sign suggests Hashimoto’s hypothyroidism over autoimmune thyroid atrophy?
Goitre suggests hashimoto’s
What can an enlarged achilles tendon be indicative of?
Infiltration of cholesterol into the tendon of primary hypercholesterolaemia, would also have xanthalasma
Three types of skin cancer
Basal cell carcinoma
Squamous cell carcinoma (deep)
Melanoma (most dangerous)
Why would you use leeches on haematoma’s on the shin and not on the arm?
The shin is right next to the skin so if a haematoma is between bone and skin it will be difficult to unite the skin again, so can use leeches
Which signs differentiate between B12 and iron deficiency in the face if someone has glossitis?
Angular cheilitis is associated with iron deficiency only.
What investigation can help you decide if someone has gas gangrene in their leg?
Xray
What will a patient tell you that indicates they have gynaecomastia rather than fatty chest?
That it onset quickly and is sore/tender
How are the blisters different in pemphigus and pemphigoid?
Pemphigus- small intra-epidermal blisters that you can push along the skin, rupture easily
Pemphigoid- thick walled large blister
How do you swap morphine PO to:
Tramadol/codeine
Diamorphine.
IV/IM/SC morphine.
x10. Tramadol
/3. Diamorphine
/2. IV/ IM/ SC morphine
Rx for palliative patient with:
A) anorexia
B) capillary bleeding under the skin
May be unlicensed:
A) anorexia- prednisolone/dexamethasone
B) cap bleeding- tranexamic acid
Pathophysiology of pemphigoid vs pemphigus
Pemphigoid- tense blisters, IgG autoantibodies to basement membrane
Pemphigus- flaccid blisters form erosions, IgG against demosomes between keratinocytes
For a controlled drug prescription what needs to be on it?
Prescriber, prescriber's address Dated Name + address of patient Form + strength Total quantity and number of dosage units (in words and figures) to be supplied
How many CPR attempts in hospital are successful?
1 in 5
For whole hospital population, not including already very unwell patients.
Which anti-emetic drug commonly precipitates in CSCI syringe drivers?
Cyclizine
What would the starting morphine dose be for someone who is opioid naive compared to someone who is taking codeine already?
Naive: 2.5-5mg / 4 hours + PRN
Taking codeine already: 5-10mg / 4 hours + PRN
What sensation often declines 20 years ahead of Parkinsons disease onset?
Loss of smell
How long should a ‘time to up and go’ test take?
10 seconds
Diagnostic of frailty
If you’re looking for metastatic disease what do you need to use in a CT scan?
Contrast, malignancy looks similar colour tissue to brain
When can you prescribe memantine in Alzheimer’s disease?
For severe dementia (MMSE
What imaging can be used to differentiate fronto-temporal dementia, Alzheimer’s and vascular when their is diagnostic doubt?
Single-photon emission CT (SPECT)
How is vascular dementia treated differently to Alzheimer’s?
Don’t give anticholinesterase inhibitors or memantine
Treatments to use and avoid for challenging behavior in dementia?
Only for SEVERE behaviour: aggression + violence to others or extreme agitation: Haloperidol IM
Olanzepine IM
not Diazepam or Chlorpromazine (typical)
Should you treat elderly patients presenting with a first seizure?
Yes, if you do imaging and there’s evidence of vascular disease or an ischemic focus they are highly likely to have another fit
Indication for DEXA scan to identify osteoporosis?
Under 75 + pathological fracture
(If over 75, just give bone protection)
Starting steroids
65 years + female + risk factors
What is the target INR for a patient who has had recurrent VTEs?
3.5
How do you decide whether to load someone with warfarin or give LMWH cover?
If someone is having anticoagulation who is low risk, say AF, no need to cover.
If someone is high risk ie has an acute DVT need cover.
If you have a patient with poor renal function who needs anticoagulation would you choose a NOAC (like Dabigatran) or warfarin?
Warfarin- checked more regularly and renal impairment prevents NOAC use
