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Year 4 > geriatrics > Flashcards

geriatrics Flashcards

1
Q

what to take into account in assessment of falls

A
  • falls history
  • gait, mobility, balance and muscle weakness
  • osteoporosis risk
  • perceived functional ability and fear relating to falling
  • visual impairement
  • cognitive impairment and near exam
  • urinary incontinence
  • home hazards
  • cardio exam
  • meds review
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2
Q

who gets osteoporosis assessment

A

-all women > 65
-all men > 75
-all people over 50 if:
- previous fragility fracture
current/frequent use of glucocorticoids
- history of falls
- FH hip fracture
-other causes of secondary osteoporosis (hyperthyroidism, chronic kidney/liver disease, rheumatoid arthritis, eating disorders, lithium, chemotherapy)
-low BMI
-smoker
- alcohol intake > 14 units/week

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3
Q

prevention of osteoporosis

A

medication:

  • bisphosphonates (alendrotnic acid or IV)
  • HRT
lifestyle:
- stop smoking 
cut down on alcohol 
- exercise 
- vit D and calcium (if depleted)
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4
Q

how do you assess risk of osteoporosis

A

FRAX (predicts 10y risk % of fracture)

DEXA scan

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5
Q

aetiology of falls

A

DAME

DRUGS (antihypertensives, sedatives, opioids, psychotropics, beta blockers)

AGEING (vision changes, cognitive decline, gait, osteoarthritis)

MEDICAL (cardiac, neuro, cataracts)

ENVRONMENT (walking aids, footwear, home hazards)

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6
Q

risk factors for delirium

A
  • > 65 years
  • cognitive impairement/dementia
  • current hip fracture
  • severe illness
  • frailty
  • sensory inpairement
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7
Q

clinical presentation of delirium

A
  1. cognitive function (worsening concentration, reduced movement, confusion)
  2. perception (visual/auditory hallucinations)
  3. physical function (reduced mobility, reduced movement, changes in appetite*, restlessness, agitation, sleep disturbances)
  4. social behaviour (lack of cooperation, withdrawal*, alteration in communication, mood and/or attitude)
  • hypoactive delirium
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8
Q

interventions to prevent delirium

A
  • familiarity (people, places)
  • reorientated people (lighting, clocks, family)
  • adress dehydration and constipation
  • assess hypoxia
  • address immobility
  • adress pain
  • adress poor nutrition
  • adress sensory impairement
  • good sleep patterns/sleep hygiene
  • adress polypharmacy
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9
Q

diagnosis of delirium

A
  • clinical assessment (DSM-V criteria/CAM/CAM-ICU)
  • quick cognitive assessment (AMTS10/AMT4)
  • all 4 of the following must be present: 1. acute onset, 2. disturbances of consciousness, 3. impaired cognition or perceptual disturbances, 4. clinical evidence of acute general medical condition, intoxication or substance withdrawal
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10
Q

managing delirium

A
  • manage underlying cause
  • effective communication and reorientation (involve family/friends/same MDT)
  • if distressed: verbal/nonverbal techniques to deescalate, short term haloperidol/olanzepine
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11
Q

causes of delirium

A 
PINCH ME
Pain 
Infection 
Nutrition (B12/folate/hypothyroidism/hypoglycaemia/hypercalcaemia)
Constipation 
Hydration 
Medication 
Environment change
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12
Q

difference between delirium and dementia

A

delirium: acute, fluctuating, reversible, clouding of consciousness, psychomotor disturbances, disturbance of sleep, hallucinations (visual)
dementia: slow, irreversible, no clouding of consciousness, functional impairment

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13
Q

stroke mimics

A 
hypoglycaemia 
seizures 
sepsis 
syncope 
space occupying lesions
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14
Q

Bamford classification of strokes (location)

A
  • TACS (large cortical stroke ACA/MCA)
  • PACS (partial cortical stroke MCA/ACA)
  • POCS (posterior circulation)
  • LACS (lacunar: subcortical stroke due to small vessel disease)
  • Weber syndrome (Ipsilateral iii palsy, contra lateral weakness)
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15
Q

diagnostic criteria for TACS

A
  • unilateral weakness/sensory of face, arm and leg +
  • homonymous hemianopia +
  • higher cerebral dysfunction (dysphagia, visuospatial i.e. inattention)
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16
Q

diagnostic criteria for PACS

A

2 of the following:

  • unilateral weakness/sensory of face, arm and leg
  • homonymous hemianopia
  • higher cerebral dysfunction (dysphagia, visuospatial)
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17
Q

diagnostic criteria for POCS

A

1 of the following:

  • cerebellar or brainstem dysfunction
  • loss of consciousness
  • isolated homonymous hemianopia
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18
Q

diagnostic criteria for LACS

A

1 of the following:

  • unilateral weakness/sensory of face and arm, arm and leg or of all 3
  • pure sensory stroke
  • ataxic hemiparesis
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19
Q

classification of stokes (aetiology)

A
  • ischemic (+ haemorrhage transformation)
  • haemorrhage
  • subarachnoid haemorrhage
  • cerebral venous thrombosis
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20
Q

aetiology of ischemic stroke

A
  • thrombus (atheroma)
  • emboli (AF, calcium from heart, bacterial vegetation)
  • systemic hypo perfusion (systemic hypotension: arterial dissection, cardiac arrest)
  • cerebral venous sinus thrombosis
  • small vessel disease
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21
Q

aetiology of intracranial haemorrhage

A
  • hypertension
  • aneurysm
  • cerebral arteriovenous malformations
  • cerebral amyloid angiopathy
  • brain tumour blood vessel bleed
  • drugs
  • trauma
  • bleeding disorders
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22
Q

symptoms of intracranial haemorrhage

A
  • sudden onset headache
  • LOC
  • nausea
  • vomitting
  • delirium
  • focal/generalised seizures
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23
Q

what steps in rapid recognition of stroke

A

exclude hypoglycaemia
use ROSIER to exclude stroke mimics
perform CT

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24
Q

In what cases do you perform a non enhanced CT for stroke enquiry

A
  • indications for thrombolysis/thrombectomy
  • on aanticoag treatment
  • known bleeding tendency
  • depressive level of consciousness (GCS<13)
  • unexplained progressive fluctuation symptoms
  • papilloedema, neck stiffness or fever
  • severe headache at onset of stroke symptoms
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25
Q

management of ischemic stroke

A

RULE OUT INTRACRANIAL HAEMORRHAGE

  • alteplase (w/in 4.5 hours)
  • thrombecomy (w/in 6 hours and if in proximal anterior circulation)
  • IF can’t alteplase or thrombectomy: Aspirin 300 mg ASAP for 2w + clopidogrel lifetime
  • lifestyle and risk factor management
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26
Q

long term anti platelet treatment for stroke:

A
  • 24h post alteplase (after CT scan): aspirin 300mg for 2 weeks
  • at 2 weeks: stop aspirin, start clopidogrel 75mg OR reduce aspirin (75mg) and add modified release dipyridamole 200mg
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27
Q

management of intracranial haemorrhage

A
  • reverse DOAC or warfarin (prothrombin complex or vit K)
  • bring BP 130-140 mmHg systolic
  • potential surgery
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28
Q

complications of strokes

A
  • residual weakness
  • post stroke pain
  • dysphasia
  • hemorragia transforamtion
  • vascular dementia
  • autonomic dysfunction
  • dysphagia/aspiration pneumonia
  • incontinence
  • depression/anxiety
  • loss of independence
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29
Q

when do you consider carotid endartectomy

A

carotid stenosis > 50% symptomatic or > 70% asymptomatic

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30
Q

symptoms of acute lower limb ischema

A

5 Ps

  • pain
  • pallor
  • parasthesia
  • paralysis
  • perishing cold
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31
Q

signs of acute lower limb ischemia

A
  • cold limb
  • mottling or marbling skin
  • diminished/absent pulses
  • sensation and movement reduced
  • development of compartment syndrome with pain in calf on compression
32
Q

clinical features of TIA

A

Transient: full recovery within 24h

ischemic: are symptoms similar to stroke

attack: sudden onset?
has the symptoms spread (if so, TIA unlikely)

33
Q

risk factors for TIA

A
  • vascular :
    hypertension, smoking diabetes, PVD, IHD

-thrombotic:
AF, carotid stenosis, contraceptive pill, clotting disorders, polycythaemia

34
Q

TIA mimics and how to differentiate them

A 
- syncope 
  TIA no TLoC
- atypical seizure 
   followed by postictal state, repetitive and stereotypical, Todd's paresis
- migraine 
   headache, symptoms evolve over time 
- temporal artritis 
   temporal artsy tenderness, jaw claudication  visual impairment 
- retinal haemorrhage or detachment 
   unilateral visual loss
- hypoglycaemia 
- labyrinthine disorders
   presenting with vertigo
35
Q

initial management of TIA

A
  • aspirin 300mg daily
  • referral to specialist within 24h of onset
  • CT/MRI
36
Q

secondary management of TIA

A
  • manage aortic stenosis, AF, hypertension, hyperlipidaemia, diabetes etc
  • clopidogrel 75mg (first line)
    modified release dipyridamole+ aspirin (second line)
37
Q

what scoring system for AF

A 
CHADS2VASC
age 
sex
CHF
hypertension
stroke/TIA/thromboembolism 
vascular disease
diabetes
38
Q

causes of TIA

A

embolus from plaque rupture (carotid stenosis) or from thrombus in heart (AF)

39
Q

what scoring systems for strokes

A

NIH
ROSIER (distinguish between acute stroke ad mimics)
GCS

40
Q

tremor differential diagnosis

A 
Parkinsonism 
essential tremor 
cerebellar tremor 
hyperthyroidism 
drug induced
41
Q

symptoms/signs of PD

A

TRAP
resting tremor, rigidity, akinesia, postural instability

non movement: anosmia, GIT problems, REM sleep behaviour disorder, prominent pain, micrographia

behavioural impairment: cognitive disturbances, impulsive behaviour, depression, anxiety, fatigue

42
Q

clinical diagnosis of PD

A
  • bradykinesia + one of the following: rigidity, ring tremor, postural instability
  • unilateral onset and persistent asymmetry
  • good levodopa response
43
Q

pathophysiology of PD

A

Lewy body in substantial nigra pars compacta (causing death of cells and loss of dopamine)

44
Q

prognosis of PD

A

13 year average survival

45
Q

aetiology of PD

A

> 60years old: usually idiopathic
<40: young onset: genetic component

most common in men,, whites

46
Q

pharmacological treatments of PD

A

first line: levodopa, dopamine agonists, MAO-B inhibitors

adjuvant treatment: levodopa + dopamine agonists, MAO-B inhibitors, COMT inhibitors

47
Q

non motor symptoms management in PD

A
  • depression: antidepressants
  • impulse control disorders: reduce dopaminergic therapy
  • dementia: cholinesterase inhibitor
  • sleep disorder: modafinil, clonzepam, melatonin
  • orthostatic hypotension: midodrine
  • psychotic symptoms: reduce dopaminergic therapy, clozapine
  • constipation: laxatives
48
Q

causes of parkinsonism

A
  • idiopathic PD
  • drug induced (symmetrical bradykinesia, history of drugs)
  • vascular (step wise progression, symmetrical)
  • dementia with Lewy Bodies (fluctuating cognitive impairment, visual hallucinations)
  • PSP
  • MSA
49
Q

history of progressive supra nuclear palsy

A
  • rapid progression
  • supra nuclear gaze palsy
  • early postural instability and falls
  • axial rigidity (hyperextended neck)
  • pseudo bulbar palsy (similar to Bell’s)
  • poor response to levodopa
50
Q

symptoms of parkinsonism

A

bradykinesia
rigidity
tremor

51
Q

6 categories of elder abuse

A 
physical
sexual 
financial 
psychology 
neglect 
racial/cultural
52
Q

how do you assess the risk factors for elder abuse

A
  • factors relating to based person
  • factors relating to perpetrator
  • relationship between both
  • environmental factors
53
Q

what is NHS continuating healthcare

A

free care outside of hospital arranged and payed by NHS

criteria: :
- similar to comprehensive geriatric assessment (high (A), medium (B) and low (C) need)

reviewed every 3 months

54
Q

pressure ulcers classification by grade

A
  • grade 1: non-blanchable erythema of intact skin (discolouration, warm, induration or hardness of skin)
  • grade 2: partial-thickness skin loss, involving epidermis, dermis or both. ulcer is superficial and presents clinically as abrasion or blister
  • grade 3: full-thickeners skin loss involving damage to or necrosis to subcutaneous tissue and may extend down to (but not through) underlying fascia
  • grade 4: extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, with or without full thickness skin loss
55
Q

what scoring system do you use for risk of developing pressure ulcers

A

waterlow score

56
Q

main factors leading to pressure ulcers

A

interface pressure
shear
friction
moisture

57
Q

def Todd’s paresis

A

focal weakness in a part or all of the body after seizure, usually subsides after 48h

58
Q

def frailty fracture

A

low energy fracture (fall from standing height or less)

59
Q

DEXA scan T scores diagnosis

A

compared to average value for young healthy person of the same race and sex as the patient

T>-1: normal
T: -1.1 to -2.4: osteopenia (low bone density)
T

60
Q

risk factors for fragility fractures

A
  • osteoporosis
  • non compliant coeliac disease
  • breast cancer
  • smoking and alcohol
  • drugs (SSRIS, omeprazole, steroid use, solace, anti epileptics)
  • age and gender
  • early menopause, late menarche
  • rheumatoid arthritis
  • immobility
61
Q

def of frailty

A

small insult can cause disproportionate change in health state

62
Q

frequent clinical presentations of frailty

A
  • non specific (extreme fatigue, unexplained weight loss, frequent infections)
  • falls
  • delirium/acute confusion
  • fluctuating disability
63
Q

fried’s phenotype model of frailty

A
  • weight loss
  • self reported exhaustion
  • low energy expenditure
  • slow gait speed
  • weak grip strength

considered frail if have at least 3 of the variables

64
Q

steps of polypharmacy review in geriatrics

A
  1. what matters to the patient
  2. identify essential therapy
  3. does the patient take necessary drug therapy
  4. are the therapeutic objectives being achieved
  5. any risk of sSE/ADRs
  6. is the drug therapy cost effective
  7. is the patient willing and able to take drug therapy as intended?
65
Q

what are the 6 domains of medication review

A 
aims
need 
effectiveness 
safety 
cost effectiveness 
patient centeredness
66
Q

Essential tremor presentation

A
  • slow progression + inherited
  • postural and worse on movement
  • affects writing and fine movement
  • bilateral
  • coarse
  • yes-yes head titubation
  • jaw and leg tremor may be present
  • improvement with alcohol use and beta blockers
  • worse with anxiety, salbutamol
67
Q

tremors worse at rest

A

parkinsonism

68
Q

tremors worse on movement

A 
essential tremor 
hyperthyroidism 
dystonic tremor 
drug induced 
exaggerated physiological tremor
69
Q

intention tremors

A

cerebellar disorders

70
Q

presentation of multiple system atrophy

A
  • parkinsonisms
  • autonomic dysfunction
  • cerebellar signs

(does not respond to levodopa)

71
Q

what are the 6 key elements in assessing patients for malnutrition and treatment for it

A
  1. risk of malnutrition
  2. why is pathophysiology of dysphagia
  3. any indication for artificial nutrition?
  4. how will you manage risk of malnutrition
  5. apply 4 principles of medical ethics
  6. who else needs to be involved
72
Q

what are indications for artificial feeding

A
  • mechanical dysphagia due to obstruction
  • neurological dysphagia where prospect of recovery
  • inability to eat due to global neurological damage (with prospect of recovery)
  • nutritional requirements are increased due to malapsortion
  • for essential meds delivery
73
Q

symptoms of oropharyngeal dysphagia

A
  • choking
  • aspiration pneumonia
  • nasal regurg
74
Q

symptoms of oesophageal dysphagia

A
  • pain

- food getting stuck k

75
Q

what are the different elements of advanced care planning

A
  • advanced decisions (legally binding, refuse treatment, DNR, ceiling of care)
  • advanced statements (not legally binding, wishes of how to be treated)
  • lasting power of attorney (finances and health)
76
Q

investigations in stroke/TIA

A
  • full neuro exam/NIHSS
  • BP, ECG, glucose
  • head CT
  • carotid stenosis
  • bloods: FBC, clotting, glucose, lipids

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