Geriatrics & Cardiology Flashcards
1
Q
What are the 3 D’s of cognitive impairment?
- 3 Neurological causes?
- 3 Psychiatric causes?
- 3 “Classics”?
A
3 D’s of Cognitive Impairment
1. Dementia
2. Delirium
3. Depression
2
Q
What is Mild Cognitive Impairment?
A
= Generally defined by the presence of memory difficulty and objective memory impairment but preserved ability to function in daily life.
3
Q
Compare Delirium and Dementia - 9 points?
A
Delirium - Delirium is a neurocognitive disorder characterized by impairments in attention and awareness (reduced orientation to the environment), as well as other cognitive disturbances (e.g., in memory, language, or perception).
Dementia - An acquired disorder of cognitive function that is commonly characterized by impairments in memory, speech, reasoning, intellectual function, and/or spatiotemporal awareness.
4
Q
A
5
Q
A
6
Q
Define Delirium.
- 5 Characteristic Features?
- 5 DSMV Criteria?
- 2 Additional features?
A
DEFINITION: An acute organic mental syndrome characterised by:
1. Global cognitive impairment
2. Reduced conciousness
3. Disturbed attention
4. Psychomotor activity
5. Sleep-wake cycle disturbance
7
Q
Prevalence of Delirium - Med vs. Surg?
A
8
Q
List the common causes of delirium.
- 6 top ones?
- By category?
A
Causes:
1. Sepsis
2. Hypoxia
3. Biochemical disturbances
4. Constipation
5. Dehydration
6. Restraints
9
Q
A
10
Q
List 8 drugs that are believed to cause or prolong delirium or confusional states?
A
Drugs and drug groups that commonly cause or contribute to delirium
1. Alcohol and illicit drugs (eg cannabis, methamfetamine)
2. Anticholinergics
3. Corticosteroids
4. Dopaminergic drugs (eg levodopa, dopamine agonists, catechol-O-methyltransferase [COMT] inhibitors)
5. Opioids
6. NSAIDs
7. Propranolol and sotalol
8. Psychotropics—especially benzodiazepines.
11
Q
Causes of Delirium:
- 5 Metabolic?
- 3 Infection?
- 9 Drugs/Toxins?
- 7 Cardiorespiratory?
- 7 Other?
A
I WATCH DEATH: Infection, Withdrawal, Acute metabolic disorder, Trauma, CNS pathology, Hypoxia, Deficiencies, Endocrine, Acute vascular, Toxins/drugs, and Heavy metals are the major causes of delirium.
12
Q
5 Predisposing Factors of Delirium?
6 Precipitating Factors for Delirium?
A
Predisposing Factors:
1. Dementia
2. Impaired ADLs
3. Age >80
4. Severe Illness
5. Visual & hearing impairment
Precipitating Factors:
1. Intercurrent illness
2. Infections
3. Metabolic disturbances
4. Hypotension
5. Etoh
6. Intracranial pathology
13
Q
Clinical features of Delirium?
A
The main symptom is an acute (hours to days) alteration in the level of awareness and attention.
Other features may include:
1. Disorganized thinking
2. Illusions
3. Hallucinations (mostly visual)
4. Cognitive deficits (e.g., memory)
5. Reversal of the sleep-wake cycle
6. Emotional lability
7. Agitation, combativeness
8. Alterations in psychomotor activity may occur.
The severity of symptoms fluctuates throughout the day and worsens in the evening (termed sundowning).
Symptoms are reversible; their duration and severity depend on the underlying illness.
14
Q
How is Delirium diagnosed?
- 4 Components of CAM?
A
Delirium is diagnosed clinically. Further studies should be conducted to determine the underlying etiology.
- DSMV (more for research)
- Confusion Assessment Method (CAM) = simple, higher inter-rater reliability and sensitivity, high specificity.
15
Q
What are 2 bedside tests of attention?
A
16
Q
Which investigations would you order for a patient with suspected delirium?
A
Routine laboratory studies
The following studies are recommended in all patients with a new presumptive delirium diagnosis.
1. Complete blood count
2. Serum glucose
3. Electrolytes
4. Urinalysis: abnormalities related to UTI (e.g., pyuria, bacteriuria) or renal failure (e.g., urinary casts)
17
Q
What is the 4AT test? 4 components?
A
4AT = more sensitive but less specific than CAM
18
Q
List 17 first line investigations to order when determining the aetiology of delirium?
A
19
Q
List 4 second line investigations to order when determining the aetiology of delirium?
A
20
Q
List 4 third line investigations to order when determining the aetiology of delirium?
A
21
Q
Describe an approach to the assessment and management of delirium?
- List 8 support measures?
A
Evaluation & Management
1. Cognitive evaluation (MMSE, CAM, Collateral history)
2. Search for underlying aetiology (Note neuroimaging and LP are only indicated in <5%)
22
Q
6 ways to try to prevent delirium/complications?
A
- Early detection & treatment of complications
- Correct fluid and electrolyte abnormalities
- Stopping unnecessary meds
- Treat severe pain
- Regulation of bowel & bladder function
- Early mobilisation/rehab
- Over one-third of cases of delirium can be prevented with nonpharmacological strategies.
- ## Uninterrupted sleep is particularly important in patients with delirium, who may experience a worsening of neuropsychiatric symptoms in the evening and at night known as sundowning.
23
Q
When are pharmaceuticals indicated in the management of delirium? What would you prescribe? Complications of these meds?
A
Indications - Patients with severe agitation which causes:
1. Interruption of essential medical treatment (eg. intubation)
2. Pose safety hazard to staff, other patients, themselves
- Avoid antipsychotics in patients with underlying alcohol withdrawal or benzodiazepine withdrawal (due to the risk of seizures) and in patients at high risk for QTc prolongation (due to the risk of torsades de pointes).
- Cholinesterase inhibitors have not been shown to be effective in the prevention or treatment of delirium. However, patients requiring long-term treatment cholinesterase inhibitors can continue to use them.
- Benzodiazepines are deliriogenic. Do not treat delirious patients with benzodiazepines unless the delirium is due to alcohol or benzodiazepine withdrawal.
24
Q
List 4 non-pharmaceutical measures to manage agitation in a delirius patient?
A
25
13 Do's of Delirium Management?
- 5 Dont's?
- 4 Tips?
TIPS
1. Patients often have multiple causes of delirium
2. Normal tests do not necessary exclude delirium
3. Beware the undiagnosed head injury as a cause of delirium - esp. in NOAC patients, always question an informant about falls, head injury or other trauma
4. Examine patient carefully for signs of trauma
26
What are the 3 types of delirium?
List 5 reasons why delirium is an important condition to prevent?
1. **Hyperactive delirium**: the patient has agitation, restlessness, hallucinations or delusions.
2. **Hypoactive delirium**: the patient is quiet and withdrawn. Hypoactive delirium is the most prevalent form of delirium but is not as obvious and often missed.
3. **Mixed delirium**: the patient alternates between hyperactive and hypoactive states.
27
**What causes a fall? 3 Threats?**
- 3 Consequences of falls?
- 3 Costs of falls?
Falls usually occurs when a threat to the normal homeostatic mechanisms that maintain postural stability is superimposed on age-related declines in balance, ambulation, and cardiovascular dysfunction.
Threat:
1. Acute illness
2. Environmental Stress
3. Unsafe walking surface
28
List 11 Risk factors for falls?
1. Age
2. Female
3. Past fall
4. Cognitive impairment
5. Lower limb weakness
6. Balance disturbance
7. Psychotropic meds
8. Arthritis
9. Past CVA
10. Orthostatic hypotension
11. Dizziness
29
Why worry about falls in the elderly? (5)
1. The risk of falls increases with age.
2. Falls are the leading cause of unintentional injury in older Australians.
3. Falls are not only associated with physical injury; they can cause loss of confidence and fear of falling, resulting in the person becoming less physically active.
4. Falls are associated with loss of functional independence and quality of life.
5. Falls are associated with an increased risk of premature admission to residential care and of mortality.
30
5 Complications of Falls?
1. Post fall anxiety (fear of falling) is common, impacting on physical and social function.
2. Immobility related injuries include muscle wasting, rhabdomyolysis, pressure sores.
3. Wrist fractures are more common <75 years, while those >75 suffer more hip and pelvic fractures.
4. Falls account for ~40% of all injury related deaths.
5. People living in residential care settings are at much higher risk of falls and falls-related injuries than those living in community settings.
31
- List 10 Intrinsic Risk factors for falls?
- List 8 Extrinsic risk factors for falls?
- List 3 Precipitating Events for falls?
**Precipitating Events**
1. Trips & Slips
2. Acute medical illness
3. Change in medication
4. Dizziness
32
Describe a risk factor model for falls in the elderly?
- 3 Risk factors with increased risk of falls with major injury?
1. Past history of a fall
2. Lower-extremity weakness
3. Age
4. Female sex
5. Cognitive impairment
6. Balance problems
7. Psychotropic drug use
8. Arthritis
9. History of stroke
10. Orthostatic hypotension
11. Dizziness
12. Anemia
Factors associated with increased risk for falls with major injuries (fracture, dislocation, or laceration requiring suture) include:
1. Fall associated with syncope
2. History of previous fall with injury
3. Decreased executive function, measured by Trail Making B time
33
**Causes of Falls:**
- 3 Age related functional decline?
- 5 Environmental factors?
- 7 Neurological?
- 4 Cardiovascular?
- 3 GIT?
- 4 Metabolic?
- 3 Urogenital?
- 3 MSK?
**Age related functional decline**
1. Visual
2. Proprioceptive
3. Vestibular
**Environment**
1. Footwear
2. Home modifications
3. Behaviour
4. Safety devices
5. Social integration
34
- Why do people living with cognitive impairment fall? (4)
- What effect does location have on the risk factors for falls?
1. Impaired cognition
2. Poor attention
3. Reduced safety awareness and decision making capacity
4. Fear of falling
35
What are 6 Mechanisms of falls?
1. Syncope/Hypotension
2. Seizure
3. Dizziness/Balance
4. Gait disturbance
5. Pain/Weakness
6. Mechanical fall
36
List 7 Medications that can contribute to falls?
**Falls - Medications**
1. Antihypertensives & Cardiac
2. Antidepressants
3. Antipsychotics
4. Benzodiazepines
5. Levadopa
6. Narcotics
Toxins - eg. Alcohol
Make you drowsy, hypotensive, hyponatramic & seizure
37
List 8 functional impairments that can contribute to the risk of falls?
**Functional Impairment **
1. BP regulation
2. Central processing
3. Gait
4. Neuromotor function
5. Postural control
6. Proprioception
7. Vestibular
8. Vision
38
What questions should be asked on history taking regarding a fall?
39
If Patient presents with a fall from vertigo:
- What are 4 differentials?
- Qs about Timecourse? (3)
- Qs about Symptoms? (3)
- Qs about Other features? (4)
40
List 7 Medications associated with an increased risk of falls?
**Medications associated with increased risk of falls**
Psychoactive medications and vasoactive/cardiovascular medications are associated with an increased risk of falls.
1. Benzodiazepine (increased risk ~ 48%)
2. Antipsychotics
3. Antidepressants (including tricyclic and SSRIs)
4. Antiepileptics
5. Opioid analgesics
6. Diuretics
7. Antihypertensives including calcium channel blockers, beta blockers, prazosin, moxonidine etc.
Benzodiazepines are a very important contributor to falls, but discontinuation is often difficult because of patient dependency on these medications.
41
**Outline a framework for history taking of a fall.**
- History of presenting complaint?
42
**Outline a framework for history taking of a fall.**
- Systems Enquiry?
43
**Outline a framework for history taking of a fall.**
- Past Medical History?
- Social History?
**Social history**
1. Alcohol intake
2. Support at home – friends/family and carers
3. Mobility – use of mobility aids and when (e.g. zimmer frame downstairs only)
44
What are the 9 components of an examination for a falls patient?
45
Outline a flowchart for falls evaluation.
46
What are 5 Ways to test balance?
47
Outline at least 5 measures to prevent falls?
Measures to prevent falls and thereby reduce the incidence and severity of fractures include:
1. Improving vision
2. Adjusting drug therapy if possible (eg drugs causing sedation, altered gait or postural hypotension).
3. Minimising household risks (preferably under the guidance of an occupational therapist).
4. Providing aids for daily living (eg walking aids, rails).
5. Minimising periods of immobilisation
promoting exercise to maintain mobility, balance and strength.
48
List 5 Falls Injury Prevention strategies?
1. **Osteoporosis treatment** can improve bone integrity.
2. **Strength and balance training**: There is evidence that strength and balance retraining in postmenopausal women decreases both falls and vertebral crush fractures.
3. **Hip protectors**: Hip protectors may decrease hip fracture rates in frail and institutionalised elderly, however, there is no evidence supporting their use in fitter, community dwelling elderly. Compliance is a major issue.
4. **Anticoagulants**: The risk of bleeding complications following a fall is increased in patients on anticoagulants. Rationalisation of therapy requires consideration of the risk and benefits, undertaken on a case-by-case basis.
5. **Falls alarms**: Falls alarms may prevent complications of falls with a long lie. Compliance may affect usefulness of alarms.
49
How does normal micturition occur?
Normal micturition occurs when bladder contraction is coordinated with urethral sphincter relaxation. The central nervous system inhibits voiding until the appropriate time and coordinates and facilitates input from the lower urinary tract to start and complete voiding. The sympathetic system contracts the smooth muscle sphincter through alpha-adrenergic fibres from the hypogastric nerve. The parasympathetic nervous system contracts the bladder detrusor muscle through cholinergic fibers.
50
What is the incidence and burden of urinary Incontinence?
INCIDENCE
- 15-30% community dwelling
- 30% hospitalised
- 50% long term care
51
What are 6 major processes that control continence?
1. **Mobility** – to get to the toilet in adequate time
2. **Cognition** – to recognise the need to toilet and where to void appropriately
3. **Intact lower urinary tract** – to allow adequate storage and elimination of urine
4. **Neurology** – to coordinate the appropriate signals between bladder and brain to generate an appropriate voiding response
5. **Environment** – Appropriate access to toilets or aids with availability of carers if required.
6. **Mental health** – Anxiety and depression can impact on many bladder related symptoms.
52
Is Incontinence a diagnosis?
= NO
- Incontinence is a symptom.
- Incontinence is abnormal at any age.
- At no age does it affect the majority of individuals.
- Even with severe dementia not all people are incontinent.
- New incontinence must be investigated.
53
What are 6 things Urinary Incontinence predisposes a person to?
**Urinary Incontinence predisposes to:**
1. Rashes
2. Pressure Sores
3. Urinary tract infections
4. Falls - slipping on wet floor/rushing
5. Fractures
6. Increased risk of institutionalised care - carer can no longer look after them at home.
54
What are 12 Risk factors for Urinary incontinence?
Risk factors vary by type!
1. Age is an important risk factor for both prevalence and severity of incontinence
2. Women > men
3. Obesity: 3X risk
4. Obstetric: parity and mode of delivery (vaginal>caesarian)
5. Hysterectomy
6. Family history
7. Smoking
8. Constipation
9. Diabetes
10. Depression
11. Dementia
12. Neurological conditions
55
How can Urinary Incontinence be classified?
- Outline the 4 types?
1. **Transient** (pregnancy, UTI, in a hospital and can’t physically get there) or **established**.
2. **Type** of Incontinence – Urge (key in the door), Stress (raised intraabdominal pressure – cough etc. Common post-partum = sphincter), Overflow (enlarged prostate, fecal impaction & don’t empty bladder out and its very stretched)
3. **Neurogenic** or **Non-neurogenic**
56
List the causes of Transient Urinary Incontinence - DIAPERS?
- 7 Pharmaceuticals?
- 2 causes of excessive output?
**Pharmaceuticals**
1. Anticholinergics
2. Alpha agonists (men)
3. Alpha antagonists (women)
4. Calcium channel blockers
5. ACE Inhibitors (cough)
6. Diuretics
7. Sedatives (and alcohol)
Excessive output – high calcium, high blood sugar
57
58
What are the 4 Pathophysiological mechanisms of Established Incontinence?
**Pathophysiological mechanisms of Established Incontinence:**
1. Detrusor overactivity
2. Detrusor underactivity
3. Obstruction
4. Outlet incontinence
Each can either be neurogenic or non-neurogenic
59
60
Which types of Urinary incontinence are more common in men vs. women?
61
5 Storage LUTS symptoms?
8 Voiding LUTS?
**Storage LUTS**
1. frequency
2. nocturia
3. urgency
4. incontinence
5. altered sensation
**Voiding LUTS**
1. voiding difficulty
2. hesitancy
3. slow stream
4. intermittent stream
5. need to strain
6. terminal dribble
7. sense of incomplete emptying
8. dysuria
62
Outline an approach to a patient presenting with incontinence?
- What 5 Things are you trying to establish?
- Qs on history taking?
**Approach**:
1. History - Bladder diary
2. Examination
3. Investigations
**Establish**:
1. Type – Urgency? Overflow? Stress? Mixed?
2. Frequency
3. Pattern –
4. Medications
5. Function/QOL
63
What examination would you perform for a patient presenting with urinary incontinence?
Full Physical – Guided
Pelvic
Rectal
Neurological
Test for Stress
Must always ask about Gynae!
64
List 8 Investigations you may consider in a patient presenting with urinary incontinence?
- When should PVR be performed?
1. Voiding chart
2. U&Es
3. Calcium/Glucose
4. Midstream Urinalysis +/- MSU - specific gravity, leucocytes, pH, nitrites, blood, glucose, ketones and protein.
5. Residual volume - normal <100ml, 100-200ml can be acceptable if not associated with renal compromise or UTI, >200ml abnormal and investigate, >400ml usually catheterise.
6. Ultrasound
7. Urodynamics
8. Cystoscopy
65
What are Urodynamics? What 4 things to they test?
- Urodynamic studies (UDS) are not routinely undertaken
- They can help determine the underlying type of incontinence and inform management decisions.
- They are time-consuming and involve catheterisation. Informed consent is required.
- They are undertaken in most continence clinics.
**UDS include:**
1. Urine flow rate
2. Cystometry – pressure and volume measurement during bladder filling, storage and voiding
3. Urethral pressure profile
4. Leak point pressure – determines pressure when leakage occurs due to increase in intra-abdominal pressure e.g. cough, valsalva
66
Outline an approach to the management of urinary incontinence in a frail elderly patient?
- Initial Treatment?
**Initial treatment**: Initial treatment usually involves lifestyle modification and pelvic floor exercises. These should usually be undertaken for 3 months before considering subsequent therapies.
**Ensure**:
1. Adequate fluid intake, avoid dehydration
2. Avoiding bladder irritants such as cigarettes and caffeine
3. Management of constipation - fibre rich diet, fluids, exercise
**Environment**:
1. Maximise physical function and access to toilet or aid
2. Mobility – gait aid, exercise programs
3. Equipment – call bell, urinary bottle, commode, raised toilet seat, rails
**Toileting regimens:**
1. Prompting to void regularly, e.g., every 2 or 3 hours.
2. The effectiveness of toileting regimens varies on factors such as cognition, mobility and setting e.g., hospital or home.
3. Toileting regimens are especially relevant for people with cognitive impairment and there is a carer to prompt.
Weight loss often improves symptoms of stress incontinence but may be hard to achieve and usually takes longer.
67
6 Lifestyle factors to address for treating urinary incontinence?
**Lifestyle**
1. Dietary. Weight loss in obese women improves symptoms, especially for stress incontinence.
2. Restriction of alcohol, caffeinated and carbonated beverages.
3. Fluid restriction is not recommended.
4. Small volumes of fluids throughout the day rather than large volumes.
5. Constipation should be treated as indicated.
6. Smoking is associated with increased risk of incontinence and other health problems, but the benefit of smoking cessation on incontinence is unknown.
68
Role of pelvic floor exercises in the treatment of urinary incontinence?
69
Role of bladder training in the treatment of urinary incontinence?
70
5 Continence aids that can be used in the management of urinary incontinence?
71
**List the Pharmacological Management options of Incontinence:**
- In Peri- or postmenopausal women?
- In Stress Incontinence?
- In Overactive bladder (urge incontinence)?
- In incontinence associated with BPH?
72
Describe the role of Muscarinic Receptor Antagonists in the pharmaceutical managament of urinary incontinence?
**Muscarinic Receptor Antagonists**
- There are five subtypes of muscarinic receptors.
- The detrusor and urothelium contain mainly M2 and M3 receptors.
- M3 receptors are primarily responsible for bladder contraction.
- Common antimuscarinic adverse effects include dry mouth, blurred vision, confusion, constipation and rarely tachycardia.
73
List 4 Interventional/Surgical options for the treatment of urinary incontinence?
74
List 9 Indications for specialist referral for patients with urinary incontinence? Which services are available?
- 8 Red Flags for specialist referral?
**Indications for specialist referral**
1. Failure to respond to initial therapy
2. Severe incontinence
3. PVR >300 ml
4. Prominent lower urinary tract symptoms in men if surgery is being considered
5. Haematuria
6. Concern about urological cancer
7. Diabetes with neuropathy
8. Patients with neurological diseases e.g. Parkinson's
9. Spinal cord disease
75
Give a definition of Osteoporosis. How does it differ from Osteopenia?
**Osteoporosis**: loss of trabecular and cortical bone mass which leads to bone weakness and increased susceptibility to fractures
**Osteopenia**: decreased bone strength but less severe than osteoporosis.
- Minimal trauma fracture (fall from standing height)
- BMD (T score) <-2.5
75
When would you consider catheterisation in a patient with urinary retention?
76
What is the Epidemiology of Osteoporosis?
- Sex: ♀ > ♂ (∼ 4:1)
- Age of onset: 50–70 years
- Demographics: higher incidence in individuals of Asian, Hispanic, and northern European ancestry
77
What are the clinical features of osteoporosis?
List the 4 most common osteoporotic fractures?
Osteoporotic fractures
1. Hip
2. Vertebral
3. Pelvis, Tibia, Humerus
4. Distal forearm
78
What is the aetiology of primary osteoporosis?
2 Types?
**Peak Bone Mass**
- Hormonal
- Body Weight
- Lifestyle
**Bone Loss**
- E2 deficiency
- Ageing
**Bone Strength** - Geometry
- Fatigue Damage
- Microfractures
- Trabecular connectivity
79
**List the secondary causes of Osteoporosis:**
- 5 Endocrine?
- 4 Gastrointestinal Disorders?
- 2 Bone Marrow Disorders?
- 3 Connective Tissue Disorders?
- 5 Medications?
80
List 7 Risk factors for osteoporosis?
1. Excessive alcohol consumption
2. Cigarette smoking
3. Immobilization or inadequate physical activity
4. Malabsorption (e.g., celiac disease), malnutrition (e.g., diet low in calcium and vitamin D), anorexia
5. Low body weight
6. Family history of osteoporosis
7. Personal history of fracture
81
Describe an approach to the diagnosis of Osteoporosis.
82
**What is a Bone mineral density (BMD) assessment?**
- 2 Indications?
- Preferred modality?
- 2 Alternatives?
**Indications:**
1. Evaluation of suspected osteoporosis
2. Screening for osteoporosis in asymptomatic high-risk individuals
**Preferred modality**: dual-energy x-ray absorptiometry.
- DXA measures BMD at the lumbar spine and hip/femoral neck using two x-ray beams.
- Findings are represented in terms of BMD scores that compare results to a reference population.
**Alternatives:**
1. Peripheral DXA: measures BMD at the distal forearm
2. Quantitative computed tomography: Provides a volumetric measurement of BMD at the lumbar spine and hip & Can measure density of trabecular bone
83
List the investigations you would order to diagnose osteoporosis? (5)
84
List 4 Markers of bone Resorption and 4 markers of bone formation?
85
Describe the management of Osteoporosis (4).
86
**Bisphosphonates for Osteoporosis:**
- Indications?
- MOA?
- 4 Examples?
- 4 Adverse effects?
- Oral bisphosphonates (except enteric-coated formulations) must be taken on an empty stomach, and at least 2 hours apart from calcium, iron, magnesium and antacids, which can limit efficacy by significantly reducing absorption.
87
List 4 Non-bisphosphonate medications for the treatment of osteoporosis.
- General indications?
**General indications**
1. Alternative first-line agents in patients with contraindications to bisphosphonate therapy.
2. Second-line agents in those who do not improve with bisphosphonates or are unable to tolerate bisphosphonate therapy (e.g., due to adverse effects).
NOTE - Estrogen is not approved for the treatment of osteoporosis in women; if estrogen is prescribed to a patient with a uterus, it should always be combined with progesterone therapy to reduce the risk of endometrial hyperplasia.
88
Breifly describe the Mechanism of action of osteoporosis medications:
- Calcitonin?
- Raloxifene?
- Bisphosphonates?
- RANKL inhibitors (denusomab)?
- Strontium?
- PTH?
- Vitamin D?
**Mechanism of action: osteoporosis medication**
– **Calcitonin**: inhibits osteoclast activity and reduces real and gastrointestinal resorption of calcium
– **Raloxifene** (selective estrogen receptor modulator, SERM): suppresses chemical mediators (i.e., cytokines, TGFb), resulting in inhibition of osteoclast bone resorption and promotion of osteoclast apoptosis
– **Bisphosphonates** (alendronate, risedronate): inhibit osteoclast activity and therefore bone resorption
– **RANKL inhibitors (denosumab)**: bind to RANKL, preventing it from activating osteoclasts via the RANK receptor
– **Strontium**: activates osteoblasts and stimulates osteoclasts to produce osteoprotegerin (OPG), which inhibits RANK-RANKL binding
– **PTH/parathyroid analogs** (teriparatide): promote both osteoblast and osteoclast activity but with the net result of increased bone mass
– **Vitamin D**: increases absorption of calcium and phosphate from the gastrointestinal tract
89
What is the PBS eligibility criteria for Bone Active Treatment of Osteoporosis?
Also minimal trauma fracture
90
Outline 2 Advantages and 2 Disadvantages of Medications used for Osteoporosis treatment:
- Alendronate?
- Risedronate?
- Zoledronic acid?
- Denusomab?
91
What is the secondary cause of osteoporosis in this patient?
= Secondary hyperparathyroidism – the PTH has gone up to try to increase calcium levels – driving it is probably lack of Vitamin D = osteomalacia
92
What is the secondary cause of osteoporosis in this patient?
= Pseudohyponatraemia = multiple myeloma
93
What is the secondary cause of osteoporosis in this patient?
**Cushing's (Hypercortisolism) & Osteoporosis:**
- Increased urinary calcium excretion = hypercalciuria = low serum calcium = PTH secretion increased. Excess PTH stimulates bone resorption.
94
What is the secondary cause of osteoporosis in this patient?
Secondary hyperparathyroidism from renal impairment
95
List 10 Key illnesses in the elderly.
96
How are therapeutics altered in the elderly? (8)
97
What are the 4 “geriatric syndromes” (Geriatric Giants)?
What are 5 other conditions to consider in the elderly?
**Geriatric Giants**
1. Immobility
2. Instability
3. Incontinence
4. Impaired intellect/memory
**Also think about:**
1. Impaired vision
2. Impaired hearing
3. Delirium
4. Polypharmacy
5. Care provision
98
When is someone considered old?
Target populaitons for Comprehensive Geriatric Assessment?
- A person's chronological age is not a great indicator of their biological age.
- There is no general agreement of when a person is considered old.
- Most developed countries have accepted a definition >65 years.
- This definition does not apply well to developing countries or indigenous communities.
- For Aboriginal and Torres Strait Islander peoples, old age is often defined as older than 50 or 55 years.
99
Describe the presentation and interventions available for:
- Stress incontinence?
- Urge incontinence?
- Overflow incontinence?
- Functional incontinence?
100
What are the aged care assessment options in Australia?
- In Australia, government-funded services are available to assist people remain in their own home, or to be cared for in an aged care home. My Aged Care is the entry point for people wishing to access these government-funded services.
- Referrals do not need to be initiated by a doctor. A person may self-refer, be referred by a relative or friend, or health care professional.
101
List 9 Health professionals. who may be involved in the Comprehensive Geriatric Assessment?
102
History Taking Checklist for Geriatric assessment?
103
What are the Key Domains of the Functional Assessment of Geriatrics? (10)
104
What is the MMSE - Mini Mental State Examination?
- Domains assessed?
- Strenghts?
- Limitations?
105
Other than the MMSE, name 5 other tools available for assessing cognition?
1. MoCa
2. KICA- Kimberly Indigenous Cognitive Assessment
3. AMT - Abbreviated Mental Test
4. RUDAS - Rowland Universal Dementia Assessment Scale
5. CDT - Clock Drawing Test
106
Describe 3 Instruments for Screening for Depression in the elderly?
107
List 3 Instruments for assessing frailty in the elderly?
108
List 3 Instruments to screen for skin integrity in the elderly?
109
List 8 investigations you may order as part of the Comprehensive Geriatric Assessment?
1. Vitamin B12 & Folate
2. Vitamin D
3. Urinalysis & Urine MC&S
4. Renal Function - eGFR & Serum urea/creatinine
5. ECG
6. Chest Xray
7. LFTs
8. TFTs
110
List 5 preventive actions in the elderly?
(GP Red Book)
1. Immunisations
2. Physical activity
3. Fall Risk Screening
4. Vison & Hearing
5. Dementia screening
111
112
113
What is the definition of Syncope and Near Syncope?
- Is a seizure a syncope?
Seizures can causes sudden LOC but are not considered syncope. However, seizures must be considered in patients presenting for apparent syncope because history may be unclear/ unavailable and some seizures do not cause tonic-clonic convulsions. Furthermore, a brief (<5secs) seizure sometimes occurs with true syncope.
114
List the Syncopal Causes of Transient Loss of Consciousness:
- 3 Reflex?
- 3 Cardiac?
- 3 Orthostatic
- 3 Cerebrovascular?
115
List 5 NON-SYNCOPAL Causes of Transient Loss of Consciousness?
1. Intoxication (alcohol, sedatives)
2. Epilepsy
3. Head trauma
4. Metabolic (eg. hypoglycaemia)
5. Narcolepsy
116
Drugs that cause syncope?
117
Drugs that cause seizures?
- Withdrawal?
- Provocation?
118
119
120
List the signs & symptoms of:
- Mitral regurgitation?
- Aortic stenosis?
- Aortic regurgitation?
- Tricuspid regurgitation?
121
Describe an Approach to arrhythmias in terms of assessing the patient?
122
What are the 4 Treatment Options for Arrythmias?
1. No treatment needed
2. Simple clinical intervention (e.g. vagal maneoeuvres, fist pacing)
3. Pharmacological (drug treatment)
4. Electrical (cardioversion for tachyarrhythmia or pacing for bradyarrhythmia).
123
Describe an algorithm for assessing an adult patient with tachycardia (with pulse)?
124
How do you manage a patient who is tachycardic and unstable?
125
How do you manage a patient who is tachycardic and stable?
126
What is the definition of a broad complex tachycardia?
- What is their most likely origin?
- How do you approach these patients?
127
What are regular broad-complex tachycardias likely to be?
Management of these patients?
128
What arrythmia is this?
Wolf Parkinson White – AV re-entrant tachycardia
129
What is the most likely cause of an Irregular broad-complex tachycardia?
Other causes?
130
What is the most likely cause of an Irregular broad-complex tachycardia with variation in QRS morphology?
- Management?
131
What is the first step in identifying the cause of a Narrow complex tachycardia?
- 5 causes of Regular narrow-complex tachycardias?
- Most likely cause of an Irregular narrow-complex tachycardia?
132
What is Sinus tachycardia? How is it managed?
133
What is Re-entry?
2 Types?
3 Features?
134
What are the 4 Requisites of Re-entry?
135
What does a Typical Atrial Flutter Circuit look like?
136
What is the most likely cause of Regular narrow complex tachycardia?
137
What is Atrial flutter with regular AV conduction (often 2:1)? What type of arrythmia does it cause?
138
What is the treatment for a patient with Regular narrow complex tachycardia?
- If the patient is unstable,
with adverse features caused by the arrhythmia?
- In the absence of adverse features?
139
What arrythmia is this?
Atrial flutter - Regular narrow complex tachycardia
140
What is the treatment for a patient with a Regular narrow complex tachycardia - If the arrhythmia persists and is not atrial flutter?
141
What is the most likely cause of an Irregular narrow complex tachycardia?
- Management?
- Treatment options?
142
What arrythmia is this?
Irregular narrow complex tachycardia - AF
143
What arrythmia is this?
Irregular narrow complex tachycardia –
atrial flutter with variable AV block
144
When does anticoagulation therapy need to be considerd in patients with AF?
Scoring system?
145
Discuss the rate control treatments for patients in AF?
146
Discuss the chemical and electrical cardioversion treatments for patients in AF?
147
Describe an approach to a patient with bradycardia and a palpable pulse?
- 4 Alternatives treatments?
Alternatives include:
1. Aminophylline
2. Dopamine
3. Glucagon (if bradycardia is caused by a beta blocker or calcium channel blocker)
4. Glycopyrrolate (may be used instead of atropine).
148
What is Bradycardia?
- 4 Causes?
- Management approach?
* Consider treating any reversible causes of bradycardia identified in the initial assessment.
* If adverse features signs are present start to treat the bradycardia.
* Initial treatment for most patients is pharmacological;
* pacingis indicated for patients unresponsive to pharmacological
treatment or with risks factors for asystole.
149
How is bradycardia treated using drugs?
150
If bradycardia with adverse signs persists despite medications, what should you consider?
- How is this done?
