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Fifth Year Medicine > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Hutchinson- Gilford syndrome

Type of inheritence

A

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

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2
Q

What is Werner’s syndrome?

Type of inheritance?

A

Premature ageing that onsets in adulthood.

Autosomal recessive mutation in a DNA helicase on chromosome 8

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3
Q

4 As of Alzeihmers

A

Amnesia
Aphasia- difficulty speaking
Agnosia- can’t name things
Apraxia- difficulty doing mechanical tasks

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4
Q

What deficit in cognition occurs in depression? How would this appear on cognitive tests?

A

Poor attention and concentration
Can’t spell WORLD backwards, serial 7s
intact orientation

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5
Q

Why give donepezil over rivastigmine for people with Parkinsons?

A

Donepezil (anticholinesterase) comes as a patch rather than a pill so good when patients get swallowing difficulties

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6
Q

What drugs cause delirium in the elderly?

ABCCD

A 
Analgesics- opioids, NSAIDs
Benzodiazepine withdrawal
Anti-Cholinergics (TCAs worse than tioptropium)
Corticosteroids
Dopaminergics (Parkinson's)

Lithium

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7
Q

Metabolic causes of delirium?

A

Low Na+
Low glucose
High calcium
High urea- kidney failure

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8
Q

What are the indications for an urgent CT scan in an elderly person with confusion?

A

Headache
Decreased GCS or fluctuating (may suggest subdural bleed)
Focal neurological signs

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9
Q

Which drugs should be avoided in Parkinson’s patients?

A

Haloperidol
Metoclopramide- for nausea

(Dopamine antagonist)

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10
Q

AMTS?

A 
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

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11
Q

What are the different types of medication for osteoporosis?

BS-DT: bullsh* design tech

A

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

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12
Q

Why does Terapartide (recombinant PTH) work to increase bone density when chronically high PTH leads to bone break down?

A

Intermittent PTH stimulates osteoblasts more than osteoclasts leading to bone being built up.
Constant PTH leads to osteoclast activation and bone break down.

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13
Q

Which medications are risk factors for falling?

AABCDDS

A

Antidepressants, antipsychotics
Benzodiazepines- cognition, balance, gait
Class 1a anti-arrhythmias (Na Ch blockers, precipitate heart block- procainamide)
Digoxin- haemodynamic changes
Diuretics- lowered BP

Sedatives

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14
Q

If making decisions with the patients best interests, who has no family, who should be included in the process?

A

Look for advanced decision

Assign Independent Mental Capacity Advocate
If urgent, don’t need to wait for IMPCA but may consult afterwards

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15
Q

What is the physiology of paroxysmal nocturnal dyspnoea?

A

Whilst laying down, with reduced sensory awareness in sleep, L heart failure leads to pulmonary oedema = gasping for breath as they wake up

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16
Q

In spirometry, in a patient with a restrictive lung disease which lung function value is reduced?

A

Full vital capacity FVC

Ie in fibrosis, lack of elasticity prevents expansion of lungs.

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17
Q

In lung function tests, what happens to the residual capacity in a patient with asthma or COPD?

A

Residual capacity increases as not all the air can be expired before small airways are compressed by thoracic pressure

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18
Q

What causes bronchial breathing?

A

Harsh sounds due to firm/solid lung tissue:

Consolidation
Fibrosis
Pleural/pericardial effusion

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19
Q

What causes diminished breath sounds?

A

Reduced transmission:
Pleural effusion
pleural thickening

Reduced air entry:
Pneumothorax
Asthma, COPD

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20
Q

What causes monophonic and polyphonic wheeze?

A 
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
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21
Q

What causes crackles/crepitations?

Coarse Vs Fine?

A

Re-opening of small airways during inspiration, that were occluded from expiration.

Coarse = small airways, bronchiectasis, COPD
Fine = alveoli + interstitium, pulmonary oedema, fibrosis
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22
Q

Cause of coarse crackles?

A

Small airways opening up:

Bronchiectasis, COPD

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23
Q

Cause of fine crackles?

A

Alveoli and interstitium opening up:

Pulmonary oedema, fibrosis

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24
Q

Causes of a pleural rub?

A

Movement of visceral pleura over parietal pleura when roughened by inflammation:

Pneumonia
Pulmonary infarction

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25
Q

How does vocal resonance change in the resp exam with consolidation?

A

Increases due to improved transmission

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26
Q

Which cell types don’t divide and need to last a lifetime?

A

Neurones
Renal cells
Myocardium

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27
Q

What medication is licensed for treating restless legs (that prevents sleep) in the elderly?

A

Dopamine agonists:
Pramipexole
Ripinirole

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28
Q

Which drugs can cause sleep disturbance? (Particularly in the elderly)

A

All things used in asthma:

Theophylline (bronchodilator in asthma, TNF-i reduce inflammation)
Sympathomimetics
High dose steroids

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29
Q

Rx of delirium tremens in alcohol withdrawal?

Mechanism of action?
Who should not receive this?

A

Chlordiazepoxide

Facilitates inhibitory GABA binding to GABA-A receptors

Easily crosses placenta, not for pregnant/breastfeeding women

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30
Q

What is the differential of dementia?

A 
Acute confusional state
Depression (pseudo)
Communication difficulties- deafness, poor vision, language deficits
Parkinson's
Schizophrenia, mania
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31
Q

You notice Parkinsonian features in a patient with cognitive decline? Which type of dementia’s are more likely?

A

Lewy body dementia

Vascular dementia

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32
Q

Blood tests to exclude other causes in suspected dementia?

A 
FBC- macrocytic anaemia in alcoholism
Biochemistry- severe hypoglycaemia
ESR- syphilis/HIV 
Thyroid function
B12+ folate

If at risk:
Syphilis serology
HIV test

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33
Q

Investigations (not bloods) useful to exclude other causes in dementia?

A

CT/MRI- exclude tumour, determine if vascular disease
CXR- delirium causes ie infection
ECG- delirium cause ie MI

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34
Q

Difference between vitamin B12 and B1 deficiencies?

A

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.

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35
Q

What is the pathophysiology of Alzeihmers disease?

A

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

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36
Q

Why are Down’s patients more at risk of Alzeihmers?

A

Amyloid precursor protein is on chromosome 21

So they get more build up of amyloid-beta

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37
Q

What is the link between insulin sensitivity and Alzeihmers?

A

Amyloid-beta competes with insulin for insulin-R’s leading to abnormal glucose metabolism in neurones

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38
Q

Why are anti-cholinesterases used in Alzeihmers?

Examples of drugs?

A

Predominantly cholinergic neurones are destroyed in Alzeihmers so anticholinesterases boost ACh levels.

Donezepil, Galantamine, Rivastigmine (non-competitive)

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39
Q

What are NICE guidelines on when to start and stop prescribing AChE-inhibitors in Alzeihmers?

A

MMSE above 10 (mild or moderate)
Continue drug if cognitive/behavioural benefit
Stop if MMSE falls below 10 or no benefit

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40
Q

Which co-morbidities in Alzeihmer’s patients would you need to be careful of, when prescribing AChE-inhibitors like Donezepil?

A

If increased parasympathetic input would be problematic:

Sick sinus syndrome
Peptic ulcer -M3 R = stomach acid secretion
COPD -M R = bronchoconstriction
Urinary retention

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41
Q

Patient has been having memory problems and hallucinations/delusions. What type of dementia is most likely? What other features are characteristic?

A

Lewy-body dementia (misfolded alpha-synuclein deposits)

Postural instability, severe ‘sundowning’

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42
Q

How do you define whether a patient has Lewy body dementia or Parkinson’s?

A

If cognitive symptoms precede movement symptoms by 1 year = Lewy Body dementia

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43
Q

What characterises fronto-temporal dementia?

What differences occur if it is predominantly right sided or left sided?

A

Change in personality, social behaviour, language ability
More preserved orientation and memory than Alzeihmers

Right- behaviour
Left- language

44
Q

Pathological process causing frontotemporal dementia?

A

Intracellular microtubule assembly protein Tau accumulation.

45
Q

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?

A

CNS cysticercosis- due to Taenia solium (pork tapeworm)

Diagnose via serology tests, stool microscopy of perianal swabs
Rx: Praziquantel, albendazole

46
Q

Patient has an apraxic gait, dementia and incontinence.
What could be the rare cause?
Investigation?

A

Normal pressure hydrocephalus

CT head
Rx: CSF shunt drainage

47
Q

Patient with dementia, opthalmoplegia and myoclonus. No alcohol history (it’s not Wernicke’s).
Also fever, weight loss and diarrhoea
Diagnosis?

A

Whipple’s disease
Tropheryma whippelii leads to GI malabsorption
= arthralgia, diarrhoea, lymphadenopathy, endocarditis

Rx: ceftriaxone

48
Q

Diarrhoea, Dementia and Dermatitis
Are the triad of what?
Rx?

A

Pellagra- lack of nicotinic acid
Endemic in China and Africa

Rx: nicotinamide

49
Q

Palsy of which nerve is associated with a high-stepping gait (due to foot-drop)?

A

Common peroneal nerve

50
Q

What symptoms to ask when taking a history of a fall?

A

dizziness, light-headed
chest pain, palpitations
loss of consciousness, weakness
prodrome

PMH: peripheral neuropathy, dementia, strokes, MIs, epilepsy
DHx: antihypertensives, sedatives, antipsychotics etc

51
Q

Common causes of muscle pain/stiffness in the elderly?

MP for muscle pain

A

Myositis (viral, inclusion body, autoimmune)
Polymyalgia rheumatica (give prednisolone)
Myxoedema, hypothyroidism
Parkinson’s disease

52
Q

What causes pathological fractures from falls in elderly men?

A

Idiopathic osteoporosis

Malabsorption- Crohns, gastric surgery, coeliac
Alcohol
Steroids
Hyperparathyroidism
Hypogonadotrophic hypogonadism
53
Q

A patient has a fall and when her height is measured she is 4cm shorter than before. What may have happened?

A

Multiple vertebral fractures.

Should have kyphosis of spine too

54
Q

What is the difference between a T score and a Z score with a DEXA scan?

A

T score compares density to a pre-menopausal woman

Z score compares density to age-matched controls

55
Q

Blood tests to exclude secondary osteoporosis?

A

TFT: thyrotoxicosis
Testosterone: hypogonadotrophic hypogonadism
ESR + Ig: myeloma
Dexamethosone supression test: Cushing’s (cortisol)

56
Q

What precautions need to be taken when administering bisphosphonates (for osteoporosis)?

A

Take on an empty stomach- absorption

Remain upright for 30 minutes- reduce oesophageal ulceration

57
Q

For pain relief in those with osteoporotic bone pain what may be used?

A

Calcitonin- acts kind of oppositely to PTH

Inhibits osteoclasts, stimulates osteoblasts etc

58
Q

What is osteomalacia?

A

Reduced calcification of the osteoid matrix due to vitamin D deficiency = soft and weak bone

(Rickets for adults)

59
Q

Which drugs may cause osteomalacia?

A

Those that induce liver enzymes, increasing vit D clearance:

Antiepileptics:
Phenytoin
Carbemazepine

60
Q

What blood test findings are associated with osteomalacia?

A

Alk phosphatase is a byproduct of bone turnover
Turnover is increased because:

Low vit D = low Ca absorption in gut = low Ca = ^ PTH

61
Q

What is Paget’s disease?

A

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.

62
Q

How do osteomalacia and paget’s disease look different on xray?

A

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

63
Q

What analgesia is most effective for Paget’s disease bone pain?

A

Alendronate (bisphosphonate inhibiting osteoclasts)

64
Q

With paget’s and osteomalacia how to do calcium, phosphate and alk phos levels differ?

A

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

65
Q

Osteoarthritis Rx?

A

1st: paracetamol ± topical NSAID
2nd: + oral NSAID

Alongside: capsaicin, intra-articular steroid injection (lasts 2 weeks)

66
Q

Difference between gout and pseudogout?

A

Gout-urate (negatively birefringent)
Pseudogout- pyrophosphate (positively birefringent)

Gout- MTP of big toe, ankle, PIP joints of fingers
Pesudogout- large joints like knee

67
Q

Rx for long term prevention of gout?

A

Allopurinol

Don’t use it soon after acute attack as may precipitate another

68
Q

Which virus has been linked to Paget’s disease?

A

Parvovirus

69
Q

Features of polymyalgia rheumatica?

Which blood test

A

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

70
Q

If patient is nearing end of life and has difficulty breathing due to bubbly secretions, what can you give her?

A

Hyosine hydrobromide

71
Q

Patient is taking Amlodipine, Ramipril, Metformin, Warfarin, Omprazole, Salbutamol and gets dehydrated, with a history of renal impairment, what changes should be made?

A 
Stop metformin (lactic acidosis)
and ACEi- prevents constriction of efferent arteriole that maintains glomerular perfusion pressure when the kidney is already hypoperfused
72
Q

For a patient lying on the floor for a long time, what should you check to see if they are having rhabdomyolysis?

A

Creatinine Kinase

73
Q

What is the danger of giving nitrofurantoin in the elderly for a simple UTI

A

Is renally cleared so can accumulate with AKI

74
Q

Patient takes antihypertensives and gets sepsis, what should you do?

A

If BP is low, stop antihypertensives

75
Q

Mode of clearance by gentamycin- kidney or liver?

A

Kidney

Hence first dose may be okay, second dose might not be

76
Q

Which antibiotic should be avoided if patient is taking Warfarin?

A

Ciprofloxacin and macrolides

CytP-450 inhibitors so warfarin conc gets higher

77
Q

What is the danger of low potassium in a patient taking digoxin?

A

Digoxin toxicity- related to competition for the sodium/potassium pump. in the heart, digoxin is already causing reduction in K/Na/ATPase pump activity

78
Q

Which painkiller should you be careful of in renal failure?

A

Give lower morphine dose as it’s renally cleared (maybe).

79
Q

What neurological impact can drinking alot of alcohol have?

A

Peripheral neuropathy
Cerebellar degeneration

Vitamin-related deficiencys

80
Q

What sign suggests Hashimoto’s hypothyroidism over autoimmune thyroid atrophy?

A

Goitre suggests hashimoto’s

81
Q

What can an enlarged achilles tendon be indicative of?

A

Infiltration of cholesterol into the tendon of primary hypercholesterolaemia, would also have xanthalasma

82
Q

Three types of skin cancer

A

Basal cell carcinoma
Squamous cell carcinoma (deep)
Melanoma (most dangerous)

83
Q

Why would you use leeches on haematoma’s on the shin and not on the arm?

A

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

84
Q

Which signs differentiate between B12 and iron deficiency in the face if someone has glossitis?

A

Angular cheilitis is associated with iron deficiency only.

85
Q

What investigation can help you decide if someone has gas gangrene in their leg?

A

Xray

86
Q

What will a patient tell you that indicates they have gynaecomastia rather than fatty chest?

A

That it onset quickly and is sore/tender

87
Q

How are the blisters different in pemphigus and pemphigoid?

A

Pemphigus- small intra-epidermal blisters that you can push along the skin, rupture easily

Pemphigoid- thick walled large blister

88
Q

How do you swap morphine PO to:
Tramadol/codeine
Diamorphine.
IV/IM/SC morphine.

A

x10. Tramadol
/3. Diamorphine
/2. IV/ IM/ SC morphine

89
Q

Rx for palliative patient with:
A) anorexia
B) capillary bleeding under the skin

A

May be unlicensed:
A) anorexia- prednisolone/dexamethasone
B) cap bleeding- tranexamic acid

90
Q

Pathophysiology of pemphigoid vs pemphigus

A

Pemphigoid- tense blisters, IgG autoantibodies to basement membrane

Pemphigus- flaccid blisters form erosions, IgG against demosomes between keratinocytes

91
Q

For a controlled drug prescription what needs to be on it?

A 
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
92
Q

How many CPR attempts in hospital are successful?

A

1 in 5

For whole hospital population, not including already very unwell patients.

93
Q

Which anti-emetic drug commonly precipitates in CSCI syringe drivers?

A

Cyclizine

94
Q

What would the starting morphine dose be for someone who is opioid naive compared to someone who is taking codeine already?

A

Naive: 2.5-5mg / 4 hours + PRN

Taking codeine already: 5-10mg / 4 hours + PRN

95
Q

What sensation often declines 20 years ahead of Parkinsons disease onset?

A

Loss of smell

96
Q

How long should a ‘time to up and go’ test take?

A

10 seconds

Diagnostic of frailty

97
Q

If you’re looking for metastatic disease what do you need to use in a CT scan?

A

Contrast, malignancy looks similar colour tissue to brain

98
Q

When can you prescribe memantine in Alzheimer’s disease?

A

For severe dementia (MMSE

99
Q

What imaging can be used to differentiate fronto-temporal dementia, Alzheimer’s and vascular when their is diagnostic doubt?

A

Single-photon emission CT (SPECT)

100
Q

How is vascular dementia treated differently to Alzheimer’s?

A

Don’t give anticholinesterase inhibitors or memantine

101
Q

Treatments to use and avoid for challenging behavior in dementia?

A

Only for SEVERE behaviour: aggression + violence to others or extreme agitation: Haloperidol IM
Olanzepine IM

not Diazepam or Chlorpromazine (typical)

102
Q

Should you treat elderly patients presenting with a first seizure?

A

Yes, if you do imaging and there’s evidence of vascular disease or an ischemic focus they are highly likely to have another fit

103
Q

Indication for DEXA scan to identify osteoporosis?

A

Under 75 + pathological fracture
(If over 75, just give bone protection)
Starting steroids
65 years + female + risk factors

104
Q

What is the target INR for a patient who has had recurrent VTEs?

A

3.5

105
Q

How do you decide whether to load someone with warfarin or give LMWH cover?

A

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.

106
Q

If you have a patient with poor renal function who needs anticoagulation would you choose a NOAC (like Dabigatran) or warfarin?

A

Warfarin- checked more regularly and renal impairment prevents NOAC use

Fifth Year Medicine (32 decks)

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