Geriatrics Flashcards
what is delirium?
an acute state of fluctuating disturbance in attention, cognition and consciousness level, which can be precipitated by infection, drugs, dehydration or hypoxia
what are the subtypes of delirium?
- Hyperactive- patients will be agitated, disoriented, delusional and may experience hallucinations
- Hypoactive- patients will appear subdued, confused, disoriented and apathetic
- Mixed- fluctuating between the hyperactive and hypoactive states of delirium
causes of delirium
- Drug initiation- benzodiazepines, analgesic and anticholinergic medications are those associated most with delirium
- Withdrawal
- Vascular- stroke/ MI
- Hypoxia- respiratory/ cardiac failure
- Systemic infection- pneumonia, UTI, malaria, wounds, IV-line infection
- Metabolic derangement- hypo/hypernatremia, hypoglycaemia, uraemia
- Surgery
- Pain
- Stroke/ seizures
- Systemic organ failure
- Intracranial infection/ head injury
what are 3 differentials of delirium?
dementia, anxiety, epilepsy
investigations in delirium
- Identify cause- do FBC, U&E, LFT, blood glucose, ABG, septic screen (urine dipstick, CXR, blood cultures), ECG, EEG, CT
how would you manage a patient with delirium?
- Identify cause
- Reorientate patient- clocks, calendars etc
- Visits from friends and family
- Manage fluid balance
- Mobilize the patient
- Remove anything invasive- catheters, IV;s etc
- Review medications- discontinue any unnecessary agents
- haloperiodol to regucy agitation
how can you differentiate delirium from dementia?
Delirium- acute onset
Delirium- inattention, distractibility and disorganised thinking
what are the 4 subtypes of dementia?
Alzheimers
vascular
fronto-temporal
lewy body
what is Alzheimers dementia?
progressive, global cognitive impairment- affects visuo-spatial skill, memory, verbal abilities and executive function (planning)
what are some causes and risk factors of Alzheimers dementia?
Causes- environmental, genetic, accumulation of B-amyloid.
Risk factors- 1st degree FH, downs syndrome, depression, smoking
what is vascular dementia?
cumulative effect of multiple small strokes, focal neurological signs, usually sudden onset
what is dementia?
neurodegenerative syndrome with a progressive decline in several cognitive domains
what are the key features of fronto-temporal dementia?
personality change! Plus socially inappropriate actions, disinhibition, poor judgement, decreased motivation. Memory is preserved until later stages
what is Picks disease?
type of fronto-temporal dementia in which Pick inclusion bodies can be found on histology
what are the features of Lewy body dementia?
fluctuating cognitive impairment, detailed visual hallucinations, develops into Parkinsonism. Lew bodies (eosinophilic intracytoplasmic inclusion bodies) found in brainstem and neocortex
how is Alzheimers diagnosed?
CT/ MRI- beta amyloid plaques, neurofibrillary tangles, atrophy
how is frontotemporal dementia diagnosed?
CT-MRI- frontotemporal atrophy, Pick cells
how is vascular dementia diagnosed?
imaging will show vascular infarcts
how is Lewy body dementia diagnosed?
imaging- lewy bodies in cortex of midbrain, generalised atrophy
how is Alzheimers dementia managed?
donepezil (acetylcholinesterase inhibitors), memantine, treat depression
how is lewy body dementia managed?
acetylcholinesterase inhibitors, memantine, levodopa, physiotherapy
what medications must be avoided when treating dementia?
neuroleptics, sedatives, tricyclic antidepressants
what are some examples of acetylcholinesterase inhibitors (AChE)?
donepazil
rivastigmine
galantamine
give an example of an antiglutamatergic treatment of dementia
Memantine
what is the triad seen in Parkinsons?
extrapyramidal triad of:
- pill rolling tremor
hypertonia- cogwheel rigidity
- bradykinesia- slow to initiate movements
what are causes of Parkinsons disease?
loss of dopaminergic neurons in the substantia nigra- associated with lewy bodies
what are some non-motor symptoms of parkinsons?
- autonomic dysfunction- postural hypotension, constipation, urinary frequency/urgency, dribbling
- sleep disturbance
reduced sense of smell
what are some neurophyschiatric symptoms of parkinsons?
depression
dementia
psychcosis
what is the risk with beginning levodopa treatment in parkinsons?
efficacy reduces over time- so stronger doses needed (resulting in worse side effects and reduced response)- so usually start late
what are pharmacological treatment options for parkinsons?
- levodopa
- dopamine agonists- ropinirole
- apomorphine
- anticholinergics (orphenadrine)
- MAO-B inhibitors (rasagilline, selegiline)
- COMT inhibitors (entacapone, tolcapone)
what is the difference between 1st and 2nd degree osteoporosis?
1st- age related
2nd- related to another condition. medication
risk factors of osteoporosis
- female
- over 50
- white/asian
- post-menopausal
- FH
- alcoholism
- RA
- Steroid use (long-term prednisolone)
- thin
how is osteoporosis investigated?
DEXA scan
bloods- normal calcium, phosphate and ALP- rules out other metabolic bone diseases
what are the T score ranges from a DEXA scan
0 to -1= BMD is in the top 84%, no evience of osteoporosis
-1 to -2.5= osteopenia- risk of later osteoporotic fracture
worse than -2.5= osteoporosis
pharmacological management of osteoporosis
- bisphosphonates- alendronic acid (1st line)
- calcium and vitamin D
- HRT
causes of urinary incontinence in men
prostate enlargement
urinary retention
causes of urinary incontinence in womenn
functional incontinence- immobility (unable to reach toilet etc)
stress incontinence- coughing and laughing result in an increased intra-abdominal pressure, resulting in the loss of small, but frequent, amounts of urine
urge incontinence- sudden urge to go to the toilet- caused by detrusor overactivity
oxford bamford classification- total anterior circulation stroke (large ACA/MCA stroke)
all 3 of:
- unilateral weakness (and/or sensory deficit) of face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
oxford Bamford classification- - partial anterior circulation stroke
2 of:
- unilateral weakness (and/or sensory deficit) of face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
Oxford bamford classification- posterior circulation stroke
one of:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
Oxford bamford classification- lacunar syndrome (LACS) (subcortical- midbrain and internal capsule)
one of:
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all 3
- pure sensory loss
- ataxic hemiparesis (cerebellar and motor symptoms)
management of a stroke
- ABCDE
- o2 sats greater than 95%
- nill by mouth (risk of aspiration pneumonia)
- thrombolysis- e.g. altepase within 4.5 hours
- antiplatelet therapy- clopidogrel
what medications are associated with falls?
- benzodiazepines
- antidepressants- SSRI’s and tricyclics
- antipsychotics
- diuretics
- ACE inhibitors
- beta blockers
what is vasovagal syncope?
‘simple faint’ vagal stimulation (fright, pain, emotion) leads to hypotension and syncope
causes of postural hypotension
- drugs- vasodilators, diuretics
- chronic hypertension
- volume depletion (dehydration, haemorrhage)
- sepsis- vasodilation
clinical features of cardiac syncope
- ecg abnormalities
- chest pain
- arrythmias
- palpitations
- hypotension
- loss of conciousness
what is the sepsis 6?
3 in, 3 out:
- IV fluids, IV antibiotics, 02 sats 94%
- lactate, blood cultures, U&E’s
what are the geriatric giants?
- immobility
- instability
- intellectual impairment
- incontinence
- iatrogenesis
- inanition
clinical features of delirium
- marked memory deficit
- acute
- disordered and disorientated thinking
- worsened concentration, slow responses
- reduced mobility/ movement
what medications are associated with causing delirium
- opiates
- benzodiazepines
- zopiclone
- anticholinergics
- Dopimanergic meds
management of alcoholism
chlordiazepoxide
what is Korsakoff syndrome?
- hypothalamic damage and cerebral atrophy due to B1 deficiency
- decreased ability to acquire new memories, confabulations, lack of insight and empathy
what triad is seen in Wernicke’s encephalopathy?
- confusion
- ataxia
- opthalmoplegia
what is the sepsis 6?
- oxygen (target >94%)
- blood cultures
- IV Abx
- fluid resus
- serum lactate and Hb
- catheterise
causes of faecal incontinence
- sphincter dysfunction- due to vaginal delivery, surgical trauma
- impaired sensation- due to diabetes, MS, dementia, spinal cord problems
- idiopathic
treatment and management of faecal incontinence
- treat cause
- ensure toilet is easy to get to
- pelvic floor rehab
- loperamide
- skin care
- enemas
causes of urinary incontinence in men
prostate enlargement
causes of urinary incontinence in women
- functional incontinence
- stress- incompetent sphincter (incontinence occurs with rise in intra abdominal pressure- coughing)
- urge incontinence (precipitated by arriving home, cold, water running, caffeine- all due to detrusor overactivity)
management of stress incontinence
pelvic floor exercises
- intravaginal electrical stimulation
- duloxetine
what medications can prevent delirium?
- dexmedetomidine- sedative
- cholinesterase inhibitors- rivastigmine or donepezil
