Geriatrics

Question 1

Precipitating factors for Delirium

Answer 1

PINCHME (Mnemonic):
Pain
Infection 
Nutrition 
Constipation 
Hydration 
Medication e.g, opiates 
Environment

Question 2

Factors that distinguish delirium from dementia

Answer 2

Acute onset
Impaired consciousness
Fluctuation of symptoms - typically worse at night
Abnormal perceptions e.g, illusions and hallucinations
Agitated

Question 3

Two types of delirium

Answer 3

Hyperactive

Hypoactive

Question 4

Delirium investigations screen

Answer 4

Observations
Bloods - FBC, U&E, LFTs, CRP, TFT, folate, B12, glucose, calcium
CXR - look for infection
Urine dip - look for infection
CT head - rule out stroke or intracranial haemorrhage

Question 5

Management of delirium

Answer 5

Treat underlying cause 
Reorientation 
Modify environment if required 
DOLS 
Sedation - only use as last resource, have to be a risk to themselves or others. Give haloperidol or lorazepam (haloperidol is contraindicated in Parkinson’s)

Question 6

What are the short assessment tools that can be used to assess cognition

Answer 6

6 item cognitive impairment test (6ICT)

Abbreviated mental test score (AMTS)

Question 7

What are the longer questionnaires that can be used to assess memory and cognition

What scores would indicate dementia?

Answer 7

Mini mental state examination (MMSE): <24/30

Addenbrooke’s cognitive examination (ACE-III): <82/100

Question 8

4 types of dementia

Answer 8

Alzheimer’s
Vascular
Lewy body
Frontotemporal

Question 9

Genes associated with Alzheimer’s

Answer 9

Apoprotein E allele E4

Amyloid precursor protein (AFP) - link with Down’s syndrome

Question 10

Pathophysiology of Alzheimer’s

Answer 10

Beta amyloid protein deposits

Neurofibrillary tangles - made from accumulation of tau

Question 11

5 A’s of Alzheimer symptoms

Answer 11

Amnesia - progressive memory decline
Agnostic - inability to recognise external stimuli (e.g people)
Apraxia - difficulty in performing coordinated motor tasks
Aphasia - difficulty speaking (later sign)
Associated behaviours - e.g, psychiatric, behavioural, personality change

Question 12

Non pharmacological management of Alzheimer’s

Answer 12

Psychological - group cognitive stimulation, activities to promote exercise and wellbeing

Social - Occupational therapist, carers etc

Question 13

Biological management of Alzheimer’s

Answer 13

AChE - e.g, donepezil, rivastigmine (1st line)

Glutamate receptor antagonists - memantine (2nd line)

Question 14

What investigation must you do before starting patients on an Acetylcholinesterase inhibitor

Answer 14

ECG - as medications can alter heart rhythms

Question 15

Which AChE is contraindicated in patients with bradycardia

Answer 15

Donepezil

Question 16

Which AChE is treatment of choice for patients with co existing cardiovascular disease

Answer 16

Rivastigmine

Question 17

What do you need to check before starting patients on memantine

Answer 17

Renal function (eGFR) - as memantine should be avoided in patients with renal failure

Question 18

Which antipsychotic is the one of choice in Alzheimer’s if necessary

Answer 18

Quetiapine

Question 19

What are the types of vascular dementia

Answer 19

Stroke related - after multi or single infarct
Subcortical - caused by small vessel disease
Mixed - mix of vascular and Alzheimer’s

Question 20

Presentation of vascular dementia

Answer 20

History of sudden onset or stepwise deterioration
This is due to infarct in the brain causing brain damage

Patients may have difficulty with attention, concentration and memory

Question 21

Management of vascular dementia

Answer 21

No specific medical management (unless they have mixed dementia with Alzheimer’s)

Management is mainly psychological and social.
Aim to address cardiovascular risk factors to slow progression and prevent further infarcts

Question 22

Pathophysiology of Lewy body dementia

Answer 22

Alpha synuclein cytoplasmic inclusions (lewy bodies)

These accumulate in the substantia nigra, paralimb and neocortical areas

Question 23

Features of Lewy body dementia

Answer 23

Progressive cognitive impairment
Symptoms tend to fluctuate (in contrast to other forms of dementia)
Parkinsonism - develops later in disease
Visual hallucinations

Question 24

Diagnosis of Lewy body dementia

Answer 24

Usually clinical

DaTscan - type of SPECT brain scan used to help diagnosis

Question 25

Management of Lewy body dementia

Answer 25

Same medications as Alzheimer’s
AChE’s - donepezil, rivastigmine
NMDA inhibitors - memantine

Question 26

Which medications should you avoid in patients with Lewy body dementia

Answer 26

Neuroleptics
Antipsychotics
These can lead to irreversible Parkinsonism

Question 27

Features of Frontotemporal dementia

Answer 27

Earlier onset in age (usually before 65 years)
Relatively preserved memory and visuospatial skills
Patients have personality change and social conduct problems

Question 28

Main recognised type of frontotemporal lobar degeneration

Answer 28

Pick’s disease (frontotemporal dementia)

Question 29

Distinguishable features of pick’s disease

Answer 29

Personality change / impaired social conduct
Hyperorality - excessive sucking, lip smacking or food cravings
Increased appetite
Disinhibiton
Uncontrolled repetition of continuation of a behaviour, word or thought

Question 30

Risk Factors for Pressure ulcers

Answer 30

Malnourishment
Incontinence
Lack of mobility
Pain - leading to reduction in mobility

Question 31

Score used in assessing pressure sore risk

Answer 31

Waterlow score

Question 32

Management of pressure ulcers

Answer 32

Regular repositioning

Hydrocolloid dressings - to keep area moist and encourage ulcer healing