Geriatrics

Question 1

Elderly women often get recurrent UTIs, what is the main reason for this?

Answer 1

Oestrogen deficiency

Question 2

What is the treatment of urinary incontinence?

Answer 2

1. Pelvic floor exercises for at least 3m

2. Anticholinergic medications may be used as monotherapy or in conjunction with pelvic floor exercises.

Question 3

What drugs might exacerbate urinary incontinence?

Answer 3

Acetylcholinesterase inhibitors

Question 4

Which type of dementia is likely most susceptible to an episode of delerium leading to deterioration of baseline cognitive function?

Answer 4

Lewy-body dementia

Question 5

Give 4 potential causes of constipation in the elderly population in nursing homes.

Answer 5

1. Laxative abuse
2. Polypharmacy
3. Poor dietary habits
4. Sedentary lifestyle

Question 6

What is the MOST common cause of blindness in elderly Caucasians?

Answer 6

Macular Degeneration

Question 7

Give 4 preventative strategies that reduce the risk of hip fractures in the elderly female nursing home patient.

Answer 7

1. Oestrogen replacement therapy
2. Bisphosphonates
3. Balance and muscle strenghtening exercises
4. Hip protectors

Question 8

T/F: Calcium supplements in elderly nursing home patients reduce the likelihood of hip fractures.

Answer 8

False.

Question 9

What is the most common cause of disability in the Australian elderly population great than 65 years?

Answer 9

Arthritis

Question 10

What is the life expectancy of the ‘average’ elderly Caucasian male?

Answer 10

80yrs

Question 11

In the treatment of depression in the elderly, why do SSRIs have fewer SEs that TCAs?

Which of these is therefore first line treatment?

Answer 11

TCA (e.g. amitryptiline, doxepin) = inhibit the reuptake of
SSRIs BOTH serotonin and noradrenalin. Also blocks histamine, acetylcholine, and alpha1-adrenergic receptors conferring worse SE profile.

SSRIs (e.g. citalopram, fluoxetine) = more selective in in inhibiting reuptake of serotonin and weaker with noradrenalin, therefore fewer SEs.

SSRIs are therefore preferable and 1st line.

Question 12

In Alzheimer’s Disease - what is the pathophysiological finding on autopsy?

Answer 12

Mis-folded proteins: amyloid plaques and neurofibrillary tangles.

Question 13

In Alzheimer’s Disease - what regions of the brain are found to have hypometabolism and decreased cerebral blood flow in?

Answer 13

Parietal and temporal lobes.

Question 14

In Alzheimer’s Disease - which brain regions are likely to have ATROPHY?

Answer 14

1. Hippocampus
2. Amygdala
3. Entorhinocortex

Question 15

Why is there detrusor overactivity in the elderly?

Answer 15

• Detrusor contraction is mediated by PSNS and inhibited by SNS.
• Less inhibition leads to detrusor overactivity.

Question 16

Why do elderly patients tend to have orthostatic hypotension?

Answer 16

Decreased baroreceptor sensitivity

Question 17

Why to elderly patients tend to have a widened pulse pressure?

Answer 17

Stiffening of blood vessels cause reduced arterial compliance that leads to widened pulse pressure.

Question 18

What happens to the following parts of the heart in the elderly:

1. LA
2. LV
3. Valves

Answer 18

1. LA - enlarges
2. LV - stiffens
3. Valves - stiffens

Question 19

Which pituitary hormones are INCREASED with normal ageing?

Answer 19

ADH

FSH / LH

Question 20

T/F: insulin levels decrease with normal ageing.

Answer 20

False - INCREASED due to insulin resistance

Question 21

T/F: PTH is reduced in normal ageing.

Answer 21

False - INCREASED and associated with bone resorption

Question 22

What occurs to the following brain parameters in normal ageing:

1. Brain volume
2. Cerebral blood flow
3. Neurotransmitters

Answer 22

ALL decrease

Question 23

What type of protein deposition is found in increasing levels with the normal ageing process?

Answer 23

Neurofibrillary tangles (NFT) and amyloid deposits

Question 24

T/F: Memory loss is NOT considered a part of normal ageing.

Answer 24

True

Question 25

T/F: minor slowing in cognitive processing speed is NOT associated with normal ageing.

Answer 25

False - it is.

Question 26

With normal ageing, what occurs to the following renal characteristics: 1. Renal blood flow 2. Nephron number 3. Glomeruli number

Answer 26

ALL decrease Smaller kidney with decreased concentration capacity and reduced GFR

Question 27

Regarding renal physiology, what occurs to the following with normal ageing: 1. Serum renin and aldosterone levels 2. Vit D activation

Answer 27

Both REDUCED

Question 28

Early onset Alzeihmer's Disease (AD) is less than 1% off all and due to increased levels of amyloid beta protein. What 3 causative genotypes have been described? Are they worth testing?

Answer 28

All known to cause increase of amyloid beta protein. PS1 (presenilin 1) - chromosome 14 PS2 (presenilin 2) - chromosome 1 APP (amyloid precursor protein) - chromosome 21 Yes - worth testing

Question 29

Late onset Alzeihmer's Disease (AD) is less than 1% off all and due to increased levels of amyloid beta protein. What 1 genotypes have been described? Is it worth testing for?

Answer 29

APOE-epsilon 4 - increased likelihood for developing AD. No - no point testing, patient already with AD.

Question 30

Elderly patient have present differently with depression. Describe 4 features of an elderly patient with depression.

Answer 30

1. Poor memory / concentration 2. Irritability 3. Slowed cognition 4. Executive dysfunction

Question 31

What are the 3 types of incontinence in the elderly?

Answer 31

1. Urge incontinence: involuntary urine loss preceded by urgency 2. Stress incontinence: involuntary leakage from stress or exertion 3. Mixed incontinence: mix of above

Question 32

What is the treatment of urge incontinence in the elderly?

Answer 32

- Reduce detrusor muscle contractility | - Bladder training

Question 33

What is the treatment of stress incontinence in the elderly?

Answer 33

- Increase urethral resistance | - Bladder training and pelvic flow exercises +/- Sx

Question 34

For STRESS incontinence in the elderly sling surgery (pubovaginal/urethral) give better symptomatic relief at 1 yr compared to just pelvic floor exercises alone. Which test must precede surgery to exclude URGE incontinence? Why is this important?

Answer 34

Urodynamic studies - if urge incontinence demonstrated then the surgery may WORSEN symptoms.

Question 35

What are the 4 principles of medical decision making?

Answer 35

1. Autonomy: informed, capacity, voluntary with no coercion 2. Justice: equality 3. Beneficence 4. Non-Maleficence

Question 36

Elderly patient is too unwell and cannot make a decision regarding medical treatment. Which of the following can NOT be refused by a 'Enduring Guardian' or 'Medical Enduring Power of Attorney': 1. Withdrawal of futile or burdensome treatment by medical professionals 2. Appropriate palliative care

Answer 36

Both.

Question 37

Which of the following locations in hospital is most likely to be associated with delerium in the elderly: 1. Medical ward 2. Surgical ward 3. ED 4. ICU

Answer 37

ICU

Question 38

What are 5 parameters of Frailty in the elderly (SEWWW):

Answer 38

SEWWW: ``` Sedentary - low physical activity Exhaustion - self-reported Weight loss Weakness Walking slow ```

Question 39

T/F: Presence of frailty is a predictor of increased falls, poor recovery, protracted hospital stay, disability, need for NHP and mortality.

Answer 39

True

Question 40

T/F: Falls are more common in nursing homes compared to the community in the elderly population.

Answer 40

True: NHP (50% of population) vs. community (30% of population)

Question 41

What percentage of elderly patients have fear of falling post-fall: 1. 10% 2. 25% 3. 50% 4. 80%

Answer 41

50%

Question 42

Comment on the following clinical features of delerium in the elderly: 1. Onset 2. Course 3. Cognition / Attention / GCS 4. Delusions / hallucinations 5. Sleep-cycle 5. Emotional state

Answer 42

1. Onset - acute onset 2. Course - fluctuant 3. Cognition / Attention / GCS - fluctuant 4. Delusions / hallucinations - common 5. Sleep-cycle - reversed 5. Emotional state - labile

Question 43

Which is associated with a worse outcome, hyperactive or hypoactive delerium?

Answer 43

Hypoactive delerium

Question 44

Elderly patient is discharged after an admission with delerium. What is the % mortality at: 1. 6-12months 2. 5 years

Answer 44

HIGH 1. 6-12months - 40% 2. 5 years - 50%

Question 45

What percentage of patient has delerium NOT fully resolved at time of discharge from hospital: 1. 10% 2. 25% 3. 50% 4. 80% 5. 95%

Answer 45

95%

Question 46

T/F: Dexmedetomodine reduces post-op delerium in non-cardiac surgery patients.

Answer 46

True

Question 47

Which of the following 2 are useful in reducing the incidence of delerium in the elderly: 1. Melatonin agonist (Ramelteon) 2. 2nd generation antipsychotics (olanzepine, risperidone)

Answer 47

Both

Question 48

The NSW Guardianship Act has a clear heirachy for decision-making in a patient that cannot decide. What is the 4 tiered hierarchy? If there is a conflict - what is the means of escalation?

Answer 48

1. Court appointed or enduring guardian 2. Most recent de-facto with ongoing relationship 3. Primary unpaid carer 4. Relative or friend with close relationship Escalation = Guradianship Tribunal

Question 49

What is a biomarker for Alzeihmer's disease on a CTB?

Answer 49

Mesial temporal atrophy (aka hippocampal atrophy)