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5th year > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Functional assessment of older people?

A

ADLs:

  • Mobility including aids and appliances
  • Washing & dressing
  • Continence
  • E+D
  • Shopping, cooking and cleaning
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2
Q

COOP: Drugs that cause confusion/affect memory?

A

Anti-psychotics

Benzodiazepines

Anti-muscarinics

Opioid analgesics

Some anti-convulsants

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3
Q

COOP: Drugs with a narrow therapeutic window?

A

Digoxin

Lithium

Phenytoin

Theophyllines

Warfarin

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4
Q

COOP: Drugs with a long half-life

A

Long acting benzos (nitrazepam & Diazepam_

Fluoxetine

Glibenclamide

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5
Q

COOP: drugs that cause hypothermia?

A

Anti-psychotics

TCA

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6
Q

COOP: drugs that cause Parkinsonism or movement disorders?

A

Metoclopramide

Antipsychotics

Prochlorperazine

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7
Q

COOP: Drugs that cause bleeding?

A

NSAIDs

Warfarin

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8
Q

COOP: drugs that predispose to falls?

A

Anti-psychotics

Sedatives

Anti-hypertensives (especially a-blockers, nitrates and ACE Inhibitors)

Diuretics

Antidepressants

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9
Q

Delirium?

A

Acute confusional state:

Disturbances of consciousness

Global disturbance of cognition (including illusions and visual hallucinations), disorientation in time place or person

Psychomotor disturbance

Disturbance of sleep-wake cycle

Emotional disturbance

Clinical evidence of an acute general medical condition, intoxication or substance withdrawal

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10
Q

Delirium causes?

A 
Infection (UTI, Resp, Biliary)
Acute hypoxaemia
Electrolyte imbalance
Meds
MI
Alcohol/benzo withdrawal
Urinary retention
Faecal impaction
Neuro (Stroke, subdural haematoma, seizures), post-op
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11
Q

Delirium DDx?

A

Dementia

Depression

Mania

Schizophrenia

Dysphasia

Seizures

Conversion disorder

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12
Q

Delirium Ix?

A

AMTS
Look at drug chart

Confusion assessment method - Pt must display:

  • Presence of acute onset + fluctuating course and
  • Inattention (Counting from 20-1) and either disorganised thinking or altered level of consciousness

1st line:
Bedside: O2, urinalysis, ECG
Bloods: FBC, CRP, U+Es, Ca2+ , TFTs, LFTs, Glucose
Imaging: CXR

Consider:

  • ABG
  • CT brain
  • EEG
  • Specific cultures
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13
Q

Delirium Mx?

A

Treat underlying cause

Environment:
- Avoid overstimulation or sensory deprivation: treat in quiet side room with a clock
- Provide environmental and personal orientation
- Minimise discontinuity of care
- Encourage mobility, adequate fluids/nutrition and sleep pattern
Involve relatives and carers

Stop drugs that cause delirium

Pharmacological measures as last resort: Haloperidol 0.5mg or olanzapine

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14
Q

Falls

A

“Unintentionally coming to rest on the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness or sudden onset of paralysis as in stroke or epileptic seizure”

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15
Q

Falls Risk factors

A

Social/demographic : eg. older, living alone, previous falls

Age-related changes - decreased ability to discriminate edges, reduced peripheral sensation, muscle weakness

Poor gait/balance - postural instability

Medical problems:

  • Cognitive impairment
  • Parkinson’s
  • Cerebrovascular disease
  • Eye diseases that reduce acuity (cataracts, glaucoma, ARMD)
  • Arthritis
  • Foot problems
  • Peripheral neuropathy
  • Incontinence

Meds

  • Psychiatric (antidepressants
  • Cardiovascular meds (Anti-hypertensives)

Environmental factors:

  • Ill fitting footwear
  • Wearing bifocal or varifocal spectacles
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16
Q

Falls Ix

A

History + examination

Get up an go test (get up from chair, no arms, walk 3m turn around, return to chair and sit down again):
20 pt needs assistance

Assess for acute illness: ECG, urine dipstick, U+Es, glucose , CRP, FBC

If abnormal gait & balance or recurrent falls:
	Medication review
	AMTS
	Vision assessment
	Lying & standing blood pressure
	Cardiovascular examination
	Neurological examination
	ECG

action:

  • Tx of any medical conditions including osteoporosis
  • Referral to a gait and balance training programme (physio)
  • Information & help including education, home hazards (OT)
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17
Q

Osteoporosis - Most common areas for fractures?

A

Spine

Wrist

Hip

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18
Q

Fracture/osteoporosis investigation?

A

Plan X-ray

DEXA:

  • Normal T score of -1SD or more
  • Osteopenia: -1 to - 2.5SD
  • Osteoporosis : T score below -2.5SD

Severe (established osteoporosis) : T score below -2.5 + one or more associated fragility fractures

Bloods: FBC, ESR, U+Es, CA2+, ALP, ALP, Phosphate, TFTs, LFTs, serum electrophoresis, urinary BJP, PTH, Vitamin D

19
Q

Osteoporosis Mx?

A

Lifestyle changes: stop smoking, reduce alcohol intake, good calcium and vitamin D intake, regular weight bearing exercise
Calcium 1200mg and vitamin D 800IU

Meds:

  • Bisphosphonates
  • Raloxifene
  • Teriparatide
  • Strontium ranelate
  • Calcitonin
20
Q

Osteoporosis medication

A

Bisphosphonates:
Reduce bone turnover rate
Alendronate, risedronate and cyclic etidronate, are specifically licensed for the prevention and treatment of post-menopausal and glucocorticoid induced osteoporosis
only alendronate is licensed for use in men
1st line for secondary prevention of osteoporotic fragility in post-menopausal women
CI if patient has oesophagitis or impaired renal function

Raloxifene
2nd line for secondary prevention of osteoporotic fragility in post-menopausal women
Selective oestrogen receptor modulator
SE: increased risk of VTE and HTN

Teriparatide
2nd line for secondary prevention of osteoporotic fragility in post-menopausal women aged >65
Recombinant fragment of PTH

Strontium ranelate
Stimulates new bone formation and reduces bone resorption
SE: increased risk of VTE

21
Q

Syncope causes?

A

Postural hypotension (most common)

Neurally mediated syncope (eg. vasovagal, situational syncope (micturation syncope))

Carotid sinus hypersensitivity

Structural cardiopulmonary disease (AS)

Cardiac arrhythmias:
- Sick sinus, AV blocks, Paroxysmal SVT/ VT, Long QT

22
Q

Syncope Ix?

A

Review of medications
Cardiovascular examination
Neurological examination
Lying and standing BP
ECG
Tilt test / carotid sinus massage in patients with recurrent syncope and no structural heart disease
Cardiac investigations in patients with structural heart disease

23
Q

Stroke causes?

A

Small vessel occlusion/cerebral microangiopathy or thrombosis in situ
Cardiac emboli
Atherothromboembolism
CNS bleeds (hypertension, trauma, aneurysm rupture, anticoagulation, thrombolysis)
Other causes: sudden BP drop >40mmHg, carotid artery dissection, vasculitis, subarachnoid haemorrhage, venous sinus thrombosis, anti-phospholipid syndrome, thrombophilia, Fabry’s disease (x-linked lysosomal storage disease)

24
Q

Stroke: haemorrhagic vs ischaemic?

A

Pointers to bleeding: meningism, severe headache, coma within hours (unreliable pointers)

Pointers to ischaemia:
Carotid bruit, AF, past TIA, IHD
Cerebral infarcts: depending on site there may be contralateral sensory loss or hemiplegia – initially flaccid becoming spastic (UMN lesion); dysphasia; homonymous hemianopia; visuo-spatial

25
Q

Cerebral vs Brainstem vs Lacunar infarcts?

A

Cerebral infarcts: depending on site there may be contralateral sensory loss or hemiplegia – initially flaccid becoming spastic (UMN lesion); dysphasia; homonymous hemianopia; visuo-spatial

Brainstem infarcts: wide-range of effects including quadriplegia, disturbances of gaze and vision, locked in syndrome

Lacunar infarcts: in basal ganglia, internal capsule, thalamus and pons; 5 syndromes: ataxic hemiparesis, pure motor, pure sensory, sensorimotor and dysarthria/clumsy hand; cognition/consciousness are intact except in thalamic stroke

26
Q

Stroke Mx?

A

Protect airway
Treating hypertension may harm as autoregulation is impaired and a 20% fall may compromise cerebral perfusion
Blood glucose: 4-11mmol/L
Urgent CT/MRI if thrombolysis considered, cerebellar stroke, unusual presentation or high risk of haemorrhage
Thrombolysis: if onset of symptoms

27
Q

TIA Mx?

A 
ABCDE2
Age >60
BP > 140/90
Clinical features:
- Unilateral weakness (2 points)
- Speech disturbance but no weakness (1 point)
Duration:
>60 mins: 2 points
10-59 mins: 1 point
Diabetes: 1 point

4 or more = high risk:

  • 300mg Aspirin daily
  • Specialist assessment and Ix within 24hrs of onset of symptoms

If ABCD2 3 or less:

  • Specialist assessment w/i 1 week including decision on brain imaging
  • If vasc territory or pathology uncertain, refer for brain imaging
28
Q

Stroke: Types?

A

Bamford classification:

The following criteria should be assessed:

  1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
  2. homonymous hemianopia
  3. higher cognitive dysfunction e.g. dysphasia

Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present

Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present

Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Posterior circulation infarcts (POCI, c. 25%)
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
29
Q

Lateral medullary syndrome? (wallenberg’s)

A

PICA or vertebral artery
Features: DANVAH

Dysphagia

Ataxia (ipsilateral)

Nystagmus (ipsilateral)

Vertigo

Anaesthesia

  • Ipsilateral facial numbness + absent corneal reflex
  • Contralateral pain loss

Horner’s syndrome (ipsilateral)

30
Q

Weber’s syndrome?

A

Ipsilateral CN III palsy
Contralateral weakness

Usually unilateral lesion affecting several structures in midbrain eg. SN, corticospinal fibres, corticobulbar tract, oculomotor nerve fibres

31
Q

Millard-Gubler syndrome?

A

Pontine infarct
6th and 7th CN nuclei + corticospinal tracts
Diplopia
LMN facial palsy + loss of corneal reflex
Contralateral hemiplegia

32
Q

Locked-in syndrome?

A

Pt. is aware and cognitively intact but completely paralysed except for the eye muscles.

Causes

Ventral pons infarction: basilar artery

Central pontine myelinolysis: rapid correction of hyponatraemia

33
Q

Amaurosis fugax

A

TIA of retinal artery, causing progressive loss of vision like a curtain descending over field of vision

34
Q

Dementia Sx?

A

Deficiencies in memory, orientation, judgement, comprehension and learning.

35
Q

Alzheimer’s disease?

A

Leading cause of dementia
Onset after 40 years; can be earlier in Down’s syndrome (100% occurrence)
Sx: enduring, progressive and global cognitive impairment: visuo-spatial skill, memory, verbal abilities and executive functions are all affected; late symptoms include irritability, mood disturbance, behavioural change, psychosis, agnosia (lack of self-recognition)
Cause: accumulation of β-amyloid peptide can result in progressive neuronal damage and loss of ACh; hippocampus, amygdala, temporal neocortex and subcortical nuclei are most vulnerable to neuronal loss
Risk factors: 1st degree relative with AD; Down’s syndrome, vascular risk factors, decreased physical/cognitive activity, depression, loneliness, smoking
Rx: acetylcholinesterase inhibitors e.g. donepezil, rivastigmine & galantamine for moderate Alzehimer’s, BP control, gingko biloba

36
Q

Vascular dementia?

A

2nd most common cause
Represents cumulative effect of many small strokes
Sudden onset and stepwise deterioration is characteristic
Mx: as for stroke

37
Q

Lewy body dementia?

A

Fluctuating cognitive impairment, visual hallucinations, parkinsonism
Lewy bodies in brainstem and neocortex

Extra sensitive to anti-psychotics

38
Q

What is Pick’s disease?

A

Fronto-temporal dementia

Frontal & temporal atrophy without Alzheimer histology
Executive impairment, behavioural/personality change, early preservation of episodic memory and spatial orientation, disinhibition, hyperorality, emotional unconcern

39
Q

Other causes of dementia?

A

Alcohol/drug abuse, repeated head trauma, pellagra, Whipple’s disease, Huntington’s, CJD, Parkinson’s
Infection:
Viral: HIV, HSV, PML
Helminth: cysticerosis, toxoplasmosis
Vascular: chronic subdural haematoma
Inflammation: SLE/sarcoid
Neoplasia
Nutritional: thiamine, B12 or folate deficiencies; pellagra (B3/niacin deficiency)
Hypothyroid, hypoadrenalism, hypercalcaemia, normal pressure hydrocephalus

40
Q

Types of incontinence?

A

Urge incontinence:
Leakage accompanied by or immediately preceded by urgency
Underlying mechanism: increasing detrusor pressure or detrusor over activity
Stress incontinence:
Leakage on effort or exertion
Underlying mechanism: weakened sphincter
Mixed incontinence:
Both urge and stress incontinence
Nocturnal enuresis:
Leakage of urine during sleep
Common in children
May be a symptom of an over active detrusor muscle
Post micturition dribbling:
Leakage experienced immediately following urination often due to pooling of urine in the urethra
Continuous incontinence:
Continuous leakage of urine
Overflow incontinence:
Leakage of urine due to obstruction and a full bladder
Functional incontinence:
Bladder works normally but because of impaired mobility or mental function the person urinates inappropriately

41
Q

Urge incontinence causes?

A

Cystitis
Bladder stone
Obstruction of bladder e.g. enlarged prostate
Idiopathic detrusor overactivity
Neuropathic detrusor overactivity e.g. spinal injury, multiple sclerosis, Parkinson’s disease, spina bifida, stroke

42
Q

Urge incontinence Mx?

A

Conservative: good fluid intake of non-caffeinated drinks; planning and timing of voiding; avoiding letting the bladder get over filled; weight loss; bladder retraining

Medical:
Anticholinergics e.g. tolterodine; imipramine
Blocks receptors on the detrusor muscle
Prevents bladder contraction
SE: confusion, dry mouth, blurred vision, constipation, urinary retention, postural hypotension, oesophageal reflux
Botulinum toxin
Prevents release of acetylcholine in nerve endings
25% risk that patients will need to self-catheterise following the treatment
Sacral nerve stimulation
For refractory urge incontinence
Surgery
Clam cystoplasty – increases capacity of bladder
Urinary diversion

43
Q

Stress incontinence

A

Caused by weakness of the urinary sphincter causing leakage when extra pressure is placed on the bladder
More common in women
Women: pelvic floor weakness/sphincter damage associated with childbirth; age; menopause; previous hysterectomy; obesity
Men: age; obesity; previous prostate surgery

44
Q

Stress incontinence Mx?

A

Mx:
Conservative: pelvic floor exercises; weight loss; stopping smoking; avoiding constipation
Medical:
Duloxetine
SNRI (Increases spinchter tone)
SE: nausea, insomnia, dizziness
Surgery:
Women: colposuspension; pubovaginal slings; tension-free mid-urethral tapes (most common); injected bladder neck bulking agents
Men: injected bladder neck bulking agents; artificial sphincter

5th year (14 decks)

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