Geriatrics Flashcards
Neural causes of syncope
• Neural causes:
○ Vasovagal (most common):
§ Severe pain, fear, blood phobia
§ Orthostatic stress eg prolonged standing or in hot places
○ Situational eg micturition, Cough, sneeze
Carotid sinus hypersensitivity - while shaving, tight collar
Postural hypotension causes of syncope
Postural hypotension:
○ Autonomic failure - postprandial, medication, MSA, parkinsons, diabetic neuropathy
Hypovolemia - haemorrhage, addisons, dehydration
Cardiac arrhythmia causes of syncope
○ Long QT
○ Drug induced arrhythmia
AV conduction disease
Structural cardiopulmonary causes of syncope
○ Aortic stenosis
○ ACS
○ Pericardial tamponade
HOCM
Hx of syncope
• Was LOC complete? • How long LOC? How quickly did it come on? ○ Vasovagal is brief complete LOC not lasting more than 20 secs • Warning sx? • Recovery spontaneous and total? ○ Postictal sx - seizure • Situational trigger? • Change In meds? FHx of sudden death? - HOCM
Ix of syncope
Ix: • LS BP • Cardiac exam • ECG • FBC - anaemia Fasting BM - hypoglycaemia
Syncope differentials
Syncope differentials: • Epilepsy • Narcolepsy • Dizziness without LOC • TIA/Stroke Hypoglycaemia
Rules on driving for seizures
Seizures:
• 1st seizure - No driving for 6 mths
• Multiple seizures:
Seizure free for 12 months - may qualify for license
Rules on driving for syncope
Syncope:
• Simple faint - no restriction
• Single episode, explained & treated - 4 wks off
• Single episode, unexplained - 6 mths off
2+ eps - 12 mths off
Stroke driving rules
• 1 mth off driving may not need to inform DVLA if no residual neurological deficit
Multiple TIAs over short period of time - 3 mths off + inform DVLA
Tremor differentials and classification
Classifying tremors:
• Rest - PD (pill rolling, bradykinesia)
• Intention - Cerebellar disease
• Tremor on movement - Essential tremor, thyrotoxicosis, anxiety, drugs (beta agonists)
inheritance of essential tremor, S&S, tx
Benign auto dom condition which affects both upper limbs
S&S:
• Postural tremor worse if arms outstretched
• Improved by alcohol and rest
Tx:
• Propanolol
guillan barre S&S and causes
S&S: • Ascending weakness • Parasthesia • Hyporeflexia • Severe cases lead to muscle weakness and resp failure
Caused by: • Often triggered by infection Campylobacter jejuni • Lymphomas esp hodgkins • Pregnancy • Surgery • Drugs
Explain ROSIER tool
ROSIER tool to assess stroke likelihood:
• New onset asymmetrical facial weakness, limb weakness, speech disturbance, or visual field defect - 1 point each
• LOC or seizure = -1 point
• Stroke likely if >0 points
Tx of stroke
Acute Tx: • ABCDE • High flow o2 • Optimise BM • Ischemic stroke: ○ IV alteplase if within 4.5 hrs of symptoms ○ 300mg Aspirin • Hemorrhagic stroke: ○ Neurosurgery referral
S&S of intracranial abscess
S&S: • Fever • Headache • GCS lowered • Focal deficits • Generalised tonic clonic seizures • Meningism • Infants - Bulging fontanelles
ix and tx of intracranial abscess
Ix: • FBC • Blood cultures • LP - rules out meningitis. Only if no signs of raised ICP • CT head • Abscess aspiration for culture
Tx:
• Drain and culture
• Sepsis 6
• IV dexamethasone if cerebral oedema suspected
• Surgery - surgical excision of abscess
S&S of NPH
Wet, wobbly, and whacky:
• Urinary incontinence, gait ataxia, dementia
Ix and tx of NPH
Ix:
• Imaging reveals hydrocephalus with enlarged 4th ventricle
Tx:
• Ventriculoperitoneal shunting
Patho and S&S of degenerative cervical myelopathy
Spinal stenosis at the cervical level
S&S: • Pain in limbs and neck • Loss of motor function • Loss of sensory function - numbness • Loss of autonomic function - continence, impotence
Ix and tx of degen cerv myelopathy
Ix:
• MRI cervical spine
Tx:
• Surgical Decompression
S&S of parkinsons
S&S: • Classic triad: ○ Bradykinesia - short shuffling steps (MUST HAVE) ○ Tremor - pill rolling typical ○ Rigidity - lead pipe rigidity • Mask like facies • Drooling of saliva • Depression
Sx worse on one side than other usually
Tx of parkinsons
Tx:
• Delay tx until onset of disabling sx and then introduce dopamine receptor agonist (DRA)
• DRA:
○ Bromocriptine
○ ADR - day time somnolence, impulse control disorders
• Levodopa:
○ Reduced effectiveness over time usually 2 yrs
○ ADR - dyskinesia, dry mouth, anorexia, postural hypotension
Patho of huntingtons
Patho:
• Auto dom
• Huntingtin protein accumulates in brain and causes damage
S&S and ix of huntingtons
S&S: • Involuntary movements • Argumentative behaviour • Depression • Chorea - quick, "dancing" movements of hand and face • Rigidity • Dystonia • Dementia • Weight loss
Ix:
• FHx
• DNA analysis
• CT head
Tx of huntingtons
Tx:
• Antidepressants
• Tranqs to control chorea
S&S of multi systems atrophy
S&S:
• Parkinsonism
• Postural hypotension
• Ataxic gait - uncoordinated movements, drunk like
S&S of myasthenia gravis. when is it a crisis
S&S: • Weakness and fatiguability • Ptosis • Diplopia • Dysphagia • Dysarthria • Myasthenic crisis - Resp function affected
Ix and tx of MG
Ix:
• Ach receptor antibodies
• Tensilon test - anticholinesterase test
• CXR - look at thymus (thymus abnormal in majority)
Tx: • Anticholinesterases eg pyridostigmine • Surgery - thymectomy • Immunosuppressants - steroids, DMARDs • Myasthenic crisis - IV immunoglobulins, plasmapheresis
Patho of syringomyelia and S&S
Patho:
• Development of cysts in spinal cord that compress
S&S: • Asymmetrical initially • Wasting and weakness of arms • Spinothalamic sensory loss - pain and temp • Loss of reflexes
Causes of sensory neuropathy
Sensory neuropathy causes: • Diabetes • Alcohol • RA • Drugs • Malignancy • B12 deficiency
Causes of motor neuropathy
Motor Neuropathy causes: • Guillan Barre Motor neurone disease • Charcot-marie-tooth disease • Lead toxicity
Ix of peripheral neuropathies
Ix: • Urine dipstick • BM • FBC • B12 levels • History of alcohol
Diseases of motor neurone disease
Diseases:
• Amyotrophic lateral sclerosis
• Progressive muscular atrophy
• Bulbar palsy
S&S of MND
S&S: • Fasciculations • Absence of sensory signs/symptoms • Mix of lower motor neurone and upper motor neurone signs - eg absent reflexes in upper limb and exaggerated reflexes in lower limb • Wasting of small hand muscles
Causes of 4th nerve palsy and S&S
Cause:
• Head trauma
• CV risk factors
S&S:
• Eye is elevated
• Unable to look down and in or read
Causes of 6th nerve palsy and S&S
Cause:
• CV risk factors
• Raised ICP
• Vasculitis
S&S:
• Eye unable to abduct beyond the midline
Causes of 3rd nerve palsy and S&S
Causes:
• DM
• Vasculitis
• Posterior communicating artery aneurysm
S&S:
• Eye down and out
• Ptosis
• Pupil dilated
Causes of Horners and S&S
S&S: • Miosis (constricted pupil) • Ptosis • Anhidrosis (loss of sweating over half of face) • Apparent enopthalmos
Causes:
• Pancoast tumour
• Iatrogenic - thyroidectomy
• MS
Bells palsy patho, epi
Epidemiology:
• 20-40 years peak incidence
• Pregnant women more common
Acute, unilateral, idiopathic facial nerve palsy
S&S of bells palsy and tx
S&S:
• Lower motor neuron facial nerve palsy - FOREHEAD AFFECTED:
○ In upper motor neuron lesion, upper face is spared
• Post auricular pain
• Altered taste
• Dry eyes
Tx:
• Prednisolone
• Artificial tears
S&S of trigeminal neuralgia and tx
S&S:
• Severe unilateral pain - sudden, shock like
• Triggered by touch to face or using face
Tx:
• Carbamazepine
• Referral to neurology if no response
S&S of alzheimers, lewy body, frontotemporal dementia, vascular dementia, and normal pressure hydrocephalus and pseudodementia
Alzheimers - 50% of cases:
• Presentation:
○ Gradual with progressive cognitive decline
○ Diagnosis supported via radiology
Vascular Dementia - 25% of cases:
• Presentation:
○ CVA evidence
○ Deterioration in cognitive function
Frontotemporal Dementia - 7% of cases:
• Presentation:
○ Decline in social and personal conduct - personality change and disinhibition
○ Emotional blunting
○ Echolalia, mutism
○ Lack of insight but sparing other cognitive functions
Lewy Body Dementia - 15% of cases:
• Presentation:
○ Day to day fluctuations in cognitive performance
○ Visual hallucinations
○ Parkinsonism
○ Extreme sensitivity to anti-psychotics
Normal Pressure hydrocephalus:
• Triad of symptoms - urinary incontinence, gait ataxia, dementia. whacky, wobbly, wet
Pseudodementia:
Reversible and due to depression - SSRIs
Steps for nutrition if malnourished
Steps for nutrition:
1. Oral nutrition 2. Enriched oral nutrition - high calorie foods eg butter 3. Oral nutritional supplements - fortisip 4. Alternative routes of feeding
Alternative routes of feeding for malnourished. when to use each.
Alternative routes of feeding: • NG tube: ○ <14 days • Gastrotomy: ○ Tube feeds directly into stomach via abdo surface ○ LT feeding
How can you monitor someones nutrition?
Monitoring nutrition:
• Weight changes
• Fluid balance
• Nutrient intake - prescribed vs delivered
Mechanism of refeeding syndrome
Mechanism:
1. In the catabolic state, body turns to fat and protein metabolism which depletes phosphate 2. When body reintroduced to carbs, insulin rises which increases cellular phosphate demand. 3. Mg, sodium, potassium, and thiamine also required for cellular pumps 4. Leads to hypophosphatemia, hypomagnesemia, hypokalaemia
Pts at risk of refeeding syndrome
At risk pts:
• Very little food intake >5days, especially if already undernourished
• Undernourished - BMI <20, unintentional weight loss >5% within last 3-6 mths
CANCER
Tx of refeeding syndrome
Tx: • Before and during first 10 days of feeding: ○ Oral thiamine ○ Vitamin B complex ○ Multivitamin and mineral supplement • Monitor biochemistry - K, P, Mg
