geriatrics Flashcards
hyponatremia algorithm pseudohyponatremia
confirm hyponatremia (low na less than 135)
check the serum osmolarity (greater than 285) pseudohyponatremia
greater than 295 high osmolarity if it is 285-295 normal osmolarity
if high hyperglycaemia, mannitol, glycine
if it is normal osmolarity 825=295 than it is hyperlipidemia hyperprotienemia
hyponatremia- true hypo
Na less than 135
serum osmolality less than 285
volume
dehydrated= renal non renal determines by urine Na
renal greater than 220- renal failures addison’s disease, chronic kidney disease diuretics
non renal less than 220
fluid loss obvious vomiting diarrhoea, cutaneous loss, third space pancreatitis small bowel obstruction
hypervolemic- failures, nephrotic syndrome
euvolemic= urine osmolality greater than 500 SIADH
less than 500 normal fluid overload, severe hypothyriodism
elderly patients who lose consciousness is very serious why?
Morbidity: 1. injure themselves seriously head trauma and subdural heamatoma 2. radial fractures 3. lose confidence anxiety and depression decreased quality of life 4. lose of independence Mortality: 1. prolonged hospital stay DVT, PE 2. pressure sores 3. Urinary tract infection cost: cost to patient, family , and state.
what is morbidity
it is the state of being ill diseased or unhealthy
what is mortality?
it is the condition of being dead
What are the definitions of ischemic stroke?
reduced blood flow due to blockage of a vessel (thrombus or embolism)
inadequate pumping pressure (global hypoperfusion)
what are the definitions of hemorrhagic stroke?
reduced blood flow due to interruption of the vessel (rupture)
itself
the bleeding causes an increase in ICP that further compresses other vessels
Irritant effects of blood lead to vasospasm in other vessels.
What a re the different categories of stroke?
Ischemic
thrombotic- large or small vessel (lacunar infarcts)
Embolic- cardiac (AFIB) non cardiac (aortic arch or paradoxical embolism)
other- unknown (cryptogenic)
Hemorrhagic
intracerebral— HTN, trauma, amyloid angiopathy, illicit drug use, vascular malformations
subarachnoid— rupture of aneurysm, bleeding from vascular malformations.
subarachnoid
left MCA stroke
SPEECH (broca’s aphasia, receptive dysphasia, and sensory loss of the upper limb and arm, right homonymous hemianopia)
right MCA stroke
HEMI NEGLECT
left sensory loss and motor loss of face and upper limb. left hemineglect and left homonymous hemianopia
Bamford classification of total anterior circulation stroke?
A total anterior circulation stroke (TACS) involves a large cortical stroke affecting the areas of the brain supplied by both the middle and anterior cerebral arteries.
All three of the following need to be present for a diagnosis of TACS:
Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Bamford classification of a partial anterior circulation stroke?
A partial anterior circulation stroke (PACS) is a less severe form of TACS, in which only part of the anterior circulation has been compromised.
Two of the following need to be present for a diagnosis of PACS:
Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (dysphasia, visuospatial disorder)
A posterior circulation syndrome (POCS) Bamford classification
A posterior circulation syndrome (POCS) involves damage to the area of the brain supplied by the posterior circulation (e.g. cerebellum and brainstem).
One of the following need to be present for a diagnosis of POCS:
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
classification of a lacunar stroke Bamford classification
A lacunar syndrome (LACS) involves a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).
One of the following needs to be present for a diagnosis of LACS:
Pure sensory stroke
Pure motor stroke
Senori-motor stroke
Ataxic hemiparesis
triad of parkinson’s
rest tremor, rigidity and bradykinesia
low potency drugs PD
selegiline selective irreversible MOA B inhibitor
What is the first line treatment for Párkinson disease in patients with motor symptoms that are effecting their QOL
Levodopa with a decarboxylase inhibitor
what would you consider in patients with motor symptoms that did not effect their QOL in parkinson’s patients
dopamine agonists
MOA B inh
or levodopa
What are the side effects of Parkinson’s medication?
excessive daytime sleepiness
psychosis and hallucinations
night disturbance and nightmares
excessive spending hypersexualised behaviours (dopamine and dopamine agonist)
Gi upset and disturbance
with levodopa you can get dyskinesia and on off effects
What can you treat the dyskinesia systems of Parkinson’s with?
MOA B inhibitors discuss with a specialist
What can you treat a PD patient with psychosis with
quetipine
What can a patient with Parkinson’s disease also have with their blood pressure?
orthostatic hypotension
What is your first line medication in a patient with PD and dementia?
Anticholinesterase inhibitors
What is physiotherapy in PD used for?
For helping with motor and balance problems
What is the surgical treatment for Parkinson’s
Deep brain stimulation for patient’s with severe parkinson’s disease that is refractory to treatment.
What are the parkinson’s plus syndromes considered?
if the PD doesn’t respond to levodopa
if there is rapidly progressive dementia
early autonomic signs
gait instability occurs early
What are the Parkinson’s plus syndromes
Progressive supra nuclear palsy
Supra nuclear palsy presentation and examination findings
hx poor balance and falls Parkinsonian features examination mask like facies impaired up and down gaze (vertical gaze) increased tone and increased reflexes
What are the red flags for a parkinson’s plus syndrome?
history of CVD, TIA exposure to neurotoxins and antidopinergic agents no rest tremor symmetrical signs early falls associated with eyes signs * ophthalmoplegia pyramidal or cerebeller signs autonomic dysfunction radio progression poor response to L dopa
Multiple system atrophy presents
different types PD *striatonigral degeneration
cerebellar
autonomic failure (urinary incontinance
postural hypotension)
What is the sign radiologucally associated with Multiple system atrophy?
hot cross bun sign MRI
Progressive supra nuclear palsy what are the features of it?
Parkinsonian but predominantly falls early coginitive decline typical examination of staring eyes trunkal rigidity impaired eye movements (downgaze) cortico basal degeneration parkinsonism cognitive decline apraxia
Corticobasal ganglionic degeneration? how does it present?
frontoparietal cortical atrophy
disease tends to occcur in the 60s
LIKE PSP and MSA but with apraxia and dystonia
cognitive decline and alien limb
Diffuse lewy body dementia
Parkinson’s symptoms
neuropsychiatric disturbances- aphasia, dyscalculia, apraxia, paranoia
with dementia
progressive dementia predom
more likely to adverse effects to LEVOdopa
How do you diagnose Lewy body dementia?
clinical presentation
extrapyramidal motor symptoms (bradykinesia, dystonia, rigidity, chorea)
visual hallucinations
dementia
How can you diagnose MSA
clinical picture
1. motor abnormalities
2. autonomic dysfunction (urinary incontinance, erectile dysfunction)
3. Cerebellar symptoms (ataxia, tremor, dysarthria)
MRI hot cross bun sign
What three tests can you order to help rule out other causes in PD?
MRI - hot cross bun sign in MSA
DatSCAN- rule out a tumour
IBZM SPECT- Parkinson plus syndromes
How do you diagnose supra nuclear palsy?
- postural instability
- frontal lobe abnormalities (apathy and disinhibition)
- vertical gaze palsy
Diagnosis MRI: the hummingbird sign
showing atrophy of the midbrain structures
How is corticobasal degeneration diagnosed?
- dementia
- alien limb syndrome
- asymmetric motor abnormalities (one limb)
diagnosis? focal cortical atrophy on MRI
What are the four parkinson’s plus syndromes?
- progressive supra nuclear palsy
- corticobasal degeneration
- Multiple system atrophy
- Lewy body dementia
