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RCE > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Delirium Diagnosis

A

1) Inattention +
2) Acute onset, fluctuating course +
3) Disturbance in LOC or cognitive domain (exec function, language, visuospatial, recall) +
4) Disturbance due to medical condition/substance and NOT a pre-existing neurocog disorder

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2
Q

Grading of Dementia

A

SCI = no objective impairment and preserved function
MCI = objective impairment in 1+ cog domain, but PRESERVED ADLS/IADLS
Mild = normal ADLs, assisted with 1 iADL
Moderate = assisted with 1 ADL or 2+ iADLs
Severe = assisted with 2+ ADL, dependent
End stage = bedbound

*do not screen asymptomatic older adults for cog impairment

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3
Q

What cognitive domains does the MMSE Test?

A

All except executive function
Good for limited education (English speaking)

Dementia if <=23

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4
Q

What domains does MoCA test?

A

All
Good for educated (English speaking)

Dementia if <=26

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5
Q

What domains does RUDAS test?

A

All except attention
Good for non-western cultural upbringing, limited education

Dementia if <=22

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6
Q

What is the most sensitive test for executive function?

A

MoCA (tests it via the most tests)

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7
Q

What is the most specific test for executive function?

A

Clock draw

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8
Q

Indications to obtain imaging in work-up of dementia

A

BRAIN
BR: Bleeding Risk (on anticoagulation, head injury)
A: Atypical dz (early onset <60, rapid decline 1-2mo, shorter duration of dementia <2y, unusual cognitive presentation)
I: Intracranial lesion (Hx cancer, focal neuro deficit)
N: NPH (incontinence, gait disturbance, cognitive impairment)

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9
Q

Indications and S/E for Cholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine)

A

1) Alzheimer’s Dementia (mild-sev)
2) Mixed Alzheimer’s/Vascular dementia (mild-sev)
3) Lewy Body Dementia/Parkinson’s Dementia

S/E:

  • CVS: Bradycardia
  • GI intolerance (anorexia),
  • GU: incontinence
  • Caution in asthma, COPD, seizures
  • Avoid in unexplained syncope or conduction defects (except RBBB) bc prolongs QT
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10
Q

Diagnosis & Tx FTD

A

Dementia + >=3 of: PEALED

  • Perseveration (unable to switch btwn tasks)
  • Executive dysfunction
  • Apathy
  • hyperoraLity
  • Empathy loss
  • Disinhibition

No role for ChEIs
Trazodone or SSRI for behaviors (often paradoxical worsening to antipsychotics)
Androgen deprivation therapy for sexual disinhibition

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11
Q

Treatment BPSD

A

Non-pharm:

  • Identify triggers/ unmet needs
  • PIECES: Modify Physical, Intellectual, Emotional, Capabilities, Environmental, and Social factors
  • Nonmed Tx as good as meds (eg outdoor therapy, music, massage, touch)

Pharm:

1) Empiric pain control with standing tylenol
2) Risperidone (max 1mg/d) ONLY if:
a) pure Alzheimer’s dementia +
b) no response to no NON-pharm tx +
c) harm to self/others or distressing symptoms
* antipsychotics - 2x stroke risk, 1,6x risk death, NNH 100

New:

  • Methylphenidate for apathy (S/E wt loss) in AD
  • Pimavanserin (serotonin modulator) for psychosis in any dementia (S/E: H/A, UTI, constipation)
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12
Q

Prevention of cognitive impairment in healthy adults

A

Hearing aids
Exercise,
Cognitive training +/- social engagement
Mediterranean diet
Tx CV RFs (esp BP and lipids) earlier in life
CPAP (observational studies)
No cognitive enhancers or OTCs (eg vit B/E, folate, gingko, flavonoids, omega3)

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13
Q

Treatment MCI

A 
Exercise  (doesn't work in dementia)
Cognitive training (inconsistent benefit in dementia)
Mediterranean diet (no evidence in dementia)
No cognitive enhancers or OTCs
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14
Q

Driving and cognitive impairment

A

Report for moderate and severe dementia (loss of 1+ ADL or 2+ iADLs)

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15
Q

Treatment depression in elderly

A

Nonpharm: group based intervention, exercise, CBT

Meds:
SSRIs (1st: sertraline/duloxetine; 2nd: citalopram/ escitalopram if normal QTc) x10-12wk for effect (monitor hypoNa in 1st 2 weeks)
Mirtazepine (sleep, appetite)
Buproprion (activating)
* No paroxetine or fluoxetine bc anticholinergic

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16
Q

Risk Factors for Falls

A 
Modifiable: MOOVE FEE
Meds (Benzos, opioids, polypharmacy, antidepressants, antipsychotics)
Orthostatic hypotension
Osteoporosis screening
Vitamin D Deficiency
Environmental hazards
Footwear/foot care
Eyes (cataract repair)
Exercise (balance and strength training)

Nonmodifiable: cog decline, movement d/o, MSK, cardiac conditions

17
Q

Fall Treatment in community dwellers

A 
Exercise program >50hrs (greatest benefit)
Med review
Home safety  - OT/PT referral
Cataract repair (females only) 
VitD supplementation
Podiatry/footwear recommendations

*No real benefit in recent studies

18
Q

Fall Treatment in LONG TERM CARE

A

Multifactorial intervention: exercise, review of meds and environment hazards, assistive devices, managing incontinence
Hip protectors
Ca/Vit D
Bisphosphonate / Prolia (highest risk reduction)
D/C Physical restraints

19
Q

Drugs to reconsider in elderly

A 
NSAID
Muscle relaxants
Narcotics
Glyburide
Benzos
Z-drugs
Anticholinergics (TCAs, paroxetine, gravol, benadryl, benztropine, tolteridine, oxybutinin)
20
Q

Normal Aging: Cognition (after 70)

A

Decreased short term functions (short term and episodic long term memory, processing speed, rxn time, attention, multitask switching, abstract reasoning)

Preserved long term functions (LTM, language, cued recall, sustained attention, registration, functioning)

21
Q

Normal Aging: Neuro

A

Gait: Decreased velocity/stride length, increased stand width/time in double support

CNs: Decreased visual accommodation/ contrast sensitivity / dark adaptation / depth perception, high frequency hearing loss, diminished sense of smell

Peripheral nerves: Decreased ankle reflexes, vibration sense, proprioception

Autonomic nerves: Decreased baroreceptor response, decreased detrusor innervation, increased vascular tone causing increased sBP>DBP

Sleep: Longer to initiate, dec stage 3/4, preserved REM

22
Q

Normal Aging: CVS

A 
Systolic HTN >DBP --> increased pulse pressure
Decreased HR (subclinical brady)
HFpEF
Valve sclerosis/stenosis
LA enlargement
23
Q

Normal Aging: Resp

A

Increased RV/ERV/FRC, dead space, VQ Mismatch
Decreased: VC, FVC, FEV1, DLCO, compliance
Preserved: FEV1:FVC

24
Q

Normal Aging: Renal

A

Decreased GFR -30% dec renal mass lose 7.5 -10mL/ min/ decade
Decreased VitD hydroxylation / production
Preserved EPO production

25
Q

Normal Aging: GI

A

Increased constipation (dec motility, more water absorbed)
Increased GERD bc loss of LES tone
Preserved nutrient absorption in SB
Decreased oxidation/phase 1 liver metabolism

26
Q

Normal Aging: MSK

A

Decreased muscle and bone mass (sarcopenia) legs>arm

No focal or diffuse weakness

27
Q

Normal Aging: Endo

A

Decreased estrogen –> vulvovaginal atrophy
Decreased testosterone
Increased mean cortisol concentration –> decreased bone density, fractures, and memory loss
Increased vasopressin response to volume (less thirst)

28
Q

Confusion Assessment method (CAM)

A

1) Inattention (serial 7s, months backwards)
2) Acute onset and fluctuating (from observation)
3) Disorganized thinking (can stone float on water)
4) LOC altered (hypervigilant, somnolent)

Dx: 1 AND 2 + 3 OR 4

29
Q

Dementia risk factors

A 
Hearing loss
Less education
Smoking
Depression
Social isolation
30
Q

Vascular dementia dx

A

Cognitive impairment (any domain, often frontal/executive):
- Stepwise (post stroke) or insidious (subcortical ischemia, lacunar infarcts, white matter changes) with gait disturbance and “slow”
AND
Imaging evidence +/- temporal relationship

31
Q

BPSD (behavioural & psychological sx of dementia) Sx

A

Psychosis: delusion, hallucination, suspicious
Aggressive: verbal, physical, resist care
Agitation: restless, anxious, vocalization, repetitive action, hoarding, pacing, wandering
Depression: suicidality, sadness, guilt, hopeless
Mania: euphorea, sexual disinhibition, irritable
Apathy: amotivation, withdrawn

32
Q

Screening q’s for falls

A

Fall in past year?
Unsteady when walking?
Fear of falling?

If yes to any, look for risk factors:

  • Med review
  • Timed up and go
  • Cognitive testing
  • Px exam: neuro, MSK, CVS, vision/hearing, orthostatic BP

If NO to all 3, not at risk: educate on falls, check for vit D deficiency, offer referral for activity

33
Q

Beers criteria inappropriate meds

A

Anticholinergics, BZD, sliding scale, glyburide, NSAIDs, muscle relaxants
DDI: opioid/benzo, opioid/gabapentinoid, warfarin/macrolide
Renally cleared: cipro, septra, enox, spironolactone, gabapentin
Drug disease interaction: AchEi in syncope, metoclopramide in PD, AED in falls

34
Q

Elder abuse fracture

A

MC: humeral - but can be accidental

Zygomatic less likely accidental

35
Q

Vaccinations for elderly

A

Tdap - once per lifetime
Td (tetanus, diphtheria) q10y
Influenza - annually >65
Pneumococcal: Prevnar + Pneumovax (8wks later) 65 y
Zoster: Shingrix (non-live) vs Zostavax (live)
COVID 3 doses if >70

36
Q

Nutritional deficiency findings

A

H&N: Fragile hair (Zn, Cu), Poor night vision (vit A), Anosmia (Zn), Caries (fluoride, Angular Chelitis (Fe, B2), Goiter (Iodine)
CV: CHF (B1)
Derm: Follicular hemorrhage (C), Sun exposed dermatitis (B3), bleeding (K), poor wound healing (Zn, Fe)
Nails: koilonychyia (Fe)
MSK: OP/osteomalacia (D)
Neuro: paresthesia (B12), cog impairment (B3, 9, 12)

37
Q

Weight loss Tx

A

NonPharm: minimize restrictions, ensure oral health, high energy supplements, eat with others/assistance, exercise, nutritional support

Pharm: multivitamin, Ca 1200mg daily, Vit D 1000U daily, +/- Fe/B12
No evidence for dronabinol or megestrol acetate

38
Q

Urinary Incontinence Types

A

Stress - involuntary w/ exertion, stress, cough, sneeze
Urge (MC women)- strong need to void and involuntary
Mixed - combined stress+urge
Overflow - obstruction, neurologic
Functional - cognitive, functional mobility difficulty

39
Q

Incontinence Mx

A

First line: limit fluid intake, limit caffeine/EtOH, weight loss, treat constipation, timed voiding, kegel exercises, pessary, bladder training

Meds if refractory:
Stress - no pharm, only surgical
Urge - antcholinergics (oxybutynin and tolterodine - relax detrusor, increase bladder capacity) not v effective and ++ side effects. Other options: mirabegron (beta Ag) or botox into detrusor

RCE (18 decks)

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