Geriatrics Flashcards
Delirium Risk Factors?
Previous dementia Severe trauma (Hip fracture) >65yrs Polypharmacy Increased Frailty
Precipitants of delirium
Change in environment
Alcohol withdrawal
Hypercalcaemia, hyper/hypoglycaemia, dehydration
Infection (UTI)
Constipation
Severe pain
Significant CVS, resp, neuro or endocrine condition
Clinical Features of delirium
Withdrawn Low mood Disturbed sleep pattern Short term memory loss Agitated Visual hallucinations Poor attention
Management of delirium
Reverse the cause
First line treatment is haloperidol unless Parkinson’s, can worsen the symptoms. Therefore consider reducing Parkinson’s meds dose.
Alzheimer’s causes:
Mainly sporadic
Can be genetic
Increased risk with Down syndrome
Features of Alzheimer’s
Macroscopic- cortex and hypothalamus atrophy
Microscopic- tau tangles and amyloid plaques
Management of Alzheimer’s
Non pharm- Tailored activities for pts Pharm- Acetylcholine-esterase inhibitors (donepezil, galantamine and rivastigmine) for mild to moderate. NMDA antagonists (memantine) of contraindicated, as add-on therapy in moderate or as monotherapy in severe Alzheimer’s.
Only use antipsychotics if at risk of self harm.
Delirium over dementia
Visual hallucinations Delusions Altered level of consciousness Fluctuating symptoms (I.e. throughout the day) Agitation/fear
Reversible differential of dementia
Hypothyroidism Subdural haematoma B12/folate/thiamine deficiency Normal pressure hydrocephalus Depression Brain tumour
Primary care BT- FBC, U+E, LFTs, TFTs, glucose, B12/folate, calcium
Risk factors for falls
Previous falls Lower limb weakness Poor balance Visual impairment Cognitive impairment Fear of falls >65yrs 4+ meds Postural hypotension Depression
History of a fall
When did you fall? Where did you fall? How did you fall? Was anyone else there? Any recollection/feeling before, after or during the fall? Any injuries/pain? How did you think you fell? Systems review? PMH Social History
Why do we usually not fall?
Good perception of our sense
MSK system good
Neurological system (basal ganglia and cortical basal ganglia loop)
Mediations to review
Postural hypotension:
- Nitrates
- Diuretics
- Anticholinergics
- Antidepressants
- Beta-blockers
- L-Dopa
- ACEi
Fall due to other mechanisms:
- Benzodiazepines
- Antipsychotics
- Opiates
- Anticonvulsants
- Codeine
- Digoxin
- Sedatives
Offer multidisciplinary assessment of fall pt when…
> 2 falls in 12 months
Fall requiring medical treatment
Failure/poor performance of Turn 180 degrees or timed up and go test
Types of frontotemporal lobar degenerations
FT dementia
Chronic Progressive Aphasia
Semantic Dementia
FT dementia
<65yrs
Insidious onset
Change in personality
Intact memory and visuospatial awareness
NICE say do not treat with AChE inhibitors or NMDA antagonists
Chronic Progressive Aphasia
Non fluent aphasia
Semantic dementia
Fluent aphasia
Definition of Lewy Body Dementia
Lewy bodies in the substantia nigra, paralimbic and neocortical areas.
3 features of Lewy body dementia
Loss of memory, function and cognition early on.
Followed by Parkinsonism
Visual Hallucinations
Management of Lewy Body dementia
Manage same as Alzheimer’s
AChE inhibitors and NMDA antagonists
Avoid neuroleptics in Lewy body dementia as very sensitive and can lead to irreversible Parkinsonism
Define multi morbidity
Having two or more long term health conditions.
Risk factors include: Increasing age Female sex Low socioeconomic background Tobacco and alcohol use Poor nutrition and obesity Lack of physical activity
Common comorbidities?
Hypertension Pain Diabetes Hearing loss Depression CAD Thyroid disorders Etc
Pressure ulcers
Found on bony prominences, usually heal and sacrum due to immobility, incontinence, pain (therefore immobile) and malnourishment.
Management of a pressure ulcer
Keep moist, allows good healing (hydrogels and hydro bandages)
Avoid soap since drying out
Referral to tissue viability nurse
Surgical debridement
Don’t swab regularly as likely to have bacterial growth. Only give systemic Abx if signs of bacterial infection, I.e. cellulitis.
Vascular dementia
Stepwise deterioration in cognitive function by different mechanisms including ischameia/haemorrhage secondary to cerebrovascular disease.
Subtypes of VD
Stroke related (multi/single infarct)
Subcortical (Small vessel disease)
Mixed (Alzheimer’s and VD)
Risk factors for vascular dementia
Stroke/TIA Hx Obesity Hypertension Hyperlipidaemia Atrial fibrillation Smoking DM FHx of stroke
Symptoms of vascular dementia
Progression speed varies. Emotional disturbance Gait disturbance Speech disturbance Memory disturbance Difficulty with attention and concentration Seizures Visual disturbances, sensory or motor symptoms
Diagnosis of VD
Extensive history and examination
MRI to look for infarcts
Screen for cognitive impairment
Medication review to ensure it’s not medication related cognitive decline
Management of VD
Treat symptoms and reduce cognitive decline
Manage challenging behaviours
Music/art therapy
Pharmacological interventions are not really useful
