Geriatrics Flashcards

Question

Cerebral vs Brainstem vs Lacunar infarcts?

Answer 1

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

Answer 2

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

Answer 3

``` 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

Answer 4

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 ```

Answer 5

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)

Answer 6

Ipsilateral CN III palsy Contralateral weakness Usually unilateral lesion affecting several structures in midbrain eg. SN, corticospinal fibres, corticobulbar tract, oculomotor nerve fibres

Answer 7

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

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

Fluctuating cognitive impairment, visual hallucinations, parkinsonism Lewy bodies in brainstem and neocortex Extra sensitive to anti-psychotics

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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