Geriatrics Flashcards
Functional assessment of older people?
ADLs:
- Mobility including aids and appliances
- Washing & dressing
- Continence
- E+D
- Shopping, cooking and cleaning
COOP: Drugs that cause confusion/affect memory?
Anti-psychotics
Benzodiazepines
Anti-muscarinics
Opioid analgesics
Some anti-convulsants
COOP: Drugs with a narrow therapeutic window?
Digoxin
Lithium
Phenytoin
Theophyllines
Warfarin
COOP: Drugs with a long half-life
Long acting benzos (nitrazepam & Diazepam_
Fluoxetine
Glibenclamide
COOP: drugs that cause hypothermia?
Anti-psychotics
TCA
COOP: drugs that cause Parkinsonism or movement disorders?
Metoclopramide
Antipsychotics
Prochlorperazine
COOP: Drugs that cause bleeding?
NSAIDs
Warfarin
COOP: drugs that predispose to falls?
Anti-psychotics
Sedatives
Anti-hypertensives (especially a-blockers, nitrates and ACE Inhibitors)
Diuretics
Antidepressants
Delirium?
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
Delirium causes?
Infection (UTI, Resp, Biliary) Acute hypoxaemia Electrolyte imbalance Meds MI Alcohol/benzo withdrawal Urinary retention Faecal impaction Neuro (Stroke, subdural haematoma, seizures), post-op
Delirium DDx?
Dementia
Depression
Mania
Schizophrenia
Dysphasia
Seizures
Conversion disorder
Delirium Ix?
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
Delirium Mx?
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
Falls
“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”
Falls Risk factors
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
Falls Ix
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)
Osteoporosis - Most common areas for fractures?
Spine
Wrist
Hip
Fracture/osteoporosis investigation?
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
Osteoporosis Mx?
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
Osteoporosis medication
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
Syncope causes?
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
Syncope Ix?
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
Stroke causes?
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)
Stroke: haemorrhagic vs ischaemic?
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
Cerebral vs Brainstem vs Lacunar infarcts?
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
Stroke Mx?
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
TIA Mx?
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
Stroke: Types?
Bamford classification:
The following criteria should be assessed:
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- 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
Lateral medullary syndrome? (wallenberg’s)
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)
Weber’s syndrome?
Ipsilateral CN III palsy
Contralateral weakness
Usually unilateral lesion affecting several structures in midbrain eg. SN, corticospinal fibres, corticobulbar tract, oculomotor nerve fibres
Millard-Gubler syndrome?
Pontine infarct
6th and 7th CN nuclei + corticospinal tracts
Diplopia
LMN facial palsy + loss of corneal reflex
Contralateral hemiplegia
Locked-in syndrome?
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
Amaurosis fugax
TIA of retinal artery, causing progressive loss of vision like a curtain descending over field of vision
Dementia Sx?
Deficiencies in memory, orientation, judgement, comprehension and learning.
Alzheimer’s disease?
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
Vascular dementia?
2nd most common cause
Represents cumulative effect of many small strokes
Sudden onset and stepwise deterioration is characteristic
Mx: as for stroke
Lewy body dementia?
Fluctuating cognitive impairment, visual hallucinations, parkinsonism
Lewy bodies in brainstem and neocortex
Extra sensitive to anti-psychotics
What is Pick’s disease?
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
Other causes of dementia?
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
Types of incontinence?
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
Urge incontinence causes?
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
Urge incontinence Mx?
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
Stress incontinence
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
Stress incontinence Mx?
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
