Geritatrics- Additional conditions (Many covered in Neurology) Flashcards
Delirium Card 1
What is delirium?
3 types of delirium?
Compare dementia with delirium? - 4 key things to remember
Delirium is an acute confusional state, characterised by a disturbed consciousness and reduced cognitive function, usually in people over the age of 65.
There are 3 main types of delirium:
Hypoactive delirium (most common) – marked by lethargy and reduced motor activity
Hyperactive delirium (most recognised) – marked by agitation and increased motor activity
Mixed agitation – marked by fluctuations throughout the day
Comparison with Demmentia:
- Attention - poor in delirium vs good in demmentia
- Onset- acute in delirium (sudden change over days) not slow and insidious over months like in demmentia
- consistency - delirium fluctuates, demmentia is very stable in its presentation
- delusions and hallucinations - far more common in delirium (apart from lewy body)
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Note - Sensory impairmeent, underlying demmentia and renal impairement are all major risk factors
Delirium Card 2
- Common causes of delirium
- management
The common causes for delirium are:
PINCH ME Mnemonic
- Pain
- Infection - UTI or LRTI
- Nutrition and Hydration
- Constipation
- Medication induced or withdrawal - BZN, opiates
- Electrolyte abnormalities (e.g. hyponatraemia, hypernatraemia, or hypercalcaemia)
Management:
- Reversing the cause
- conserative measures to keep patients orientated
- However, if required Haloperidol 1st line and Lorazopam may be used to sedate aggitated patients. Antipsychotics should be avoided.
Ix for Delirium - what is included in a confusion screen? (13 - 10 are blds - try your best, not that deep)
An assessment of mental status can be completed using recognised cognitive assessment tools - e.g. 4A’s test, abbreviated mental test score AMT or MMSE
Once confusion is suspected a confusion screen can be completed to help identify the cause:
Urinalysis — to identify conditions such as infection or hyperglycaemia (diabetes). NOTE - A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.
Sputum culture — to identify chest infection.
Full blood count — to identify infection or anaemia.
Folate and B12 — to identify vitamin deficiency.
Urea and electrolytes — to identify acute kidney injury and electrolyte disturbance (such as hyponatraemia or hypokalaemia).
HbA1c — to identify hyperglycaemia.
Calcium — to identify hypercalcaemia or hypocalcaemia.
Liver function tests — to identify hepatic failure and rule out hepatic encephalopathy.
Inflammatory markers (ESR & CRP) — these tests are non-discriminatory but can help to identify infection or inflammation.
Drug levels — to identify drug toxicity, for example if the person has taken digoxin, lithium, or alcohol.
Thyroid function tests — to identify hyperthyroidism or hypothyroidism.
Chest X-ray — to identify conditions such as pneumonia and heart failure.
Electrocardiogram — to identify cardiac conditions including arrhythmias.
Define Orthostatic hypotension - including values?
Causes? - 5
Diagnosis?
Management?
Orthostatic hypotension
In simple terms, orthostatic hypotension refers to a fall in blood pressure (BP) on standing. It is broadly defined as:
Fall in systolic BP ≥ 20 mmHg or more (with or without symptoms)
Fall in systolic BP to <90mmHg on standing
Fall in diastolic BP ≥ 10 mmHg with symptoms (clinically much less significant)
Causes:
- decreased baroreceptor reflex sensitivity with age. (Normally when we stand blood pools in the lower extremities, and barorecptors fire less leading to activation of the autonomic nervous system)
- Antihypertensive and diuretic medicaitons
- hypovolemia - reduced aldosterone, Renin, increased naturetic petides with age.
- autonomic disfuntion - parkinson’s, diabetes
- cardiovascular disease - arrhythmia, heart failure, MI, aortic stenosis
The symptoms of postural hypotension are caused by cerebral hypoperfusion. They include:
Dizziness
Weakness
Confusion
Blurred vision
Nausea
In severe cases, syncope. When older patients present with syncope, a lying and standing blood pressure measurement is essential to identify postural hypotension as a potential contributor.
Diagnosis - made with lying and stading BP readings
note - possibly an ECG to rule out cardiac arrthymias
Management:
- conservative - increase hydration, compression stockings and stand more slowly
Medical management:
- Fludrocortisone - increase plasma volume can cause hypokalaemia and supine hypertension (Remember its like mineralocorticoid (aldosterone) which retains Na in exchange for K)
- Midodrine - vassopressor used for neurogenic causes (parkinsons or diabetes) but SE of urinary retention
- pyridostigmine
Postural hypotension is a significant contributor to falls in older adults.
What is syncope
What are the 3 causes of syncope?
presentation?
4 Ix for syncope
Syncope refers to a transient loss of consciousness. The loss of consciousness is usually due to a brief reduction in cerebral perfusion due to an abrupt fall in blood pressure. The loss of consciousness inevitably leads to a collapse with subsequent recovery as perfusion is restored (~8-10 seconds).
Causes:
1. Vasovagal - When the vagus nerve receives a strong stimulus, such as an emotional event, painful sensation or change in temperature it can stimulate the parasympathetic nervous system. As the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of brain tissue.
- Orthostatic hypotension (fall in BP on standing)
- Cardiac syncope -Aortic stenosis or arrthymia
Other causes of loss of conciousness not syncope (not cerebral hypoperfusion):
- seizsure
- hypoglycemia/electrolyte
- intoxication
Presentation - before during and after:
- vasovagal often has prodromal symptoms - (e.g. nausea, dizziness, visual changes, feeling hot/cold)
- Sudden collapse without warning is concerning for a cardiac cause- as is prodromal chestpain, SOB or palpatations
-A collateral history from someone that witnessed the event is essential to get an accurate impression of what happened. During a vasovagal episode they may describe the person:
Suddenly losing consciousness and falling to the ground
Unconscious on the ground for a few seconds to a minute as blood returns to their brain
There may be some twitching, shaking or convulsion activity, which can be confused with a seizure
The patient may be a bit groggy following a faint, however this is different from the postictal period that follows a seizure. Postictal patients have a prolonged period of confusion, drowsiness, irritability and disorientation.
There may be incontinence with both seizures and syncopal episodes. However tongue biting, eyes open and moving are suggestive of seizsure.
Investigations
ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome
24 hour ECG if paroxysmal arrhythmias are suspected
Echocardiogram if structural heart disease is suspected
Bloods, including a full blood count (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)
ME- Remeber CT head for elderly?/blood thinners with head injury
Management:
- dependant on cause
- if a simple vasovagal episode is diagnosed, reassurance and simple advice can be given - avoid dehydration, missing meals, standing for long periods
Avoid dehydration
Avoid missing meals
Avoid standing still for long periods
When experiencing prodromal symptoms such as sweating and dizziness, sit or lie down, have some water or something to eat and wait until feeling better
Differnetial Dx for Falls
Ix for mechanical falls (2)
Management for mechanical fall (4)
The differential diagnosis of falls is very broad. It is important to determine whether the patient has suffered a transient loss of consciousness or a simple mechanical fall.
- MSK - arthritis and osteoperosis, muscle weakness
- visual impairement or balance issues (inc BPPV)
- Neuro - Parkinsons, Stroke and TIA, congitive impairment
- cardiac syncope and orthostatic hypertension
- incontinence
- Iatrogenic - Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).
- environmental hazzards
Ix:
Basically i wouldt stress too much about specific Ix - the history + common sense is good - ECG for syncope, hit head CT - subdural haematoma
- assess their gait and balance - for example by using the Timed Up & Go test (max 15 seconds) and/or the Turn 180° test (max 4 steps)
- comprehensive falls risk assessmenet - the **FRAT tool **(falls risk assessement tool)
- If syncope suspected then its those Ix - ECG (see card)
Management of mechanical falls:
- Physio - Strength and balance training
- OT - home risk assessmenet
- medication review
- vissual assessmenet
Rhabdomyelsis following a fall and long lie (risk increases with duration):
- what is rhabdomyelsis
- why is it dangerous
- presentation
- key Ix
- management
Rhabdomyolysis involves skeletal muscle breaking down and releasing various chemicals into the blood. Muscle cells (myocytes) undergo cell death (apoptosis), releasing:
Myoglobin - can cause AKI
Potassium - hyperkalaemia causes cardiac arthymias
Phosphate
Creatine kinase
Other causes - rigerous exercise, crush injuries, seizsures, statins
Presentation:
- red-brown (coca cola) urine
- oligouria (AKI)
- muscle pain and weakness
Ix:
- KEY- serum creatine kinase rises in first 12 hours and remains elevated for 1-3 days
- urinalysis for myoglobinurea - shows as blood
- U+E for hyperkalaemia and ECG
Managment:
- IV fluids - filtration of breakdown products
- manage hyperkalaemia - IV insulin and dextrose infusion
- optional Intravenous sodium bicarbonate for myoglobinurea
Define Frailty?
What are the 5 signs of frailty?
4 clinical tests used for frailty?
What is sarcopenia?
Frailty – - A state of increased vulnerability and compromisd ability to cope with everyday stressors, resulting from ageing-assocaited decline in functional reserve, across multiple physiological systems.
Phenotype model:
- Weight loss
- Lethargy
- Slow gait
- Weak grip
- Reduced activity
Having three or more indicates frailty.
Frailty tests:
- Rockwood frailty index - ranges from very fit (1), manageing well- just walking (3), Mildly frail - support with high order IADLs (5), (6)- help with personal car, (8)- end of life - DONT LEARN JUST TO BE AWARE
- PRISMA 7 Questionnaire
- Gait speed
- Timed up and go test
Sarcopenia:
- Loss of muscle mass or function
- Based on gait speed and grip strength
- Some loss of muscle loss and power is normal with ageing, but sarcopenia is pathological. Muscle loss can be acute or chronic.
- Acute loss happens with disuse atrophy/deconditioning – rapidly loosing muscle strength and power when in hospital for example.
- Also leads to VO2 max reduction because the lungs are also powered by muscle too.
Frailty: what are the domains of a comprehensive geriatric assessment?
- Medical: problems list, medications review, nutritional status
- Functional capacity: PTs and OTs – Activities of Daily Living, Gait & Balance, Activity/exercise status
- Mental health – conditions, mood and anxiety and fears (falling)
- Social & environmental – OT and social care - informal support from family, social network and activities, care source eligibility, home safety and facilities, transport facilities.
What are the 4 geriatric giants?
Me - the geriatric giants are a group of common conditions that lead to significant morbidity (disability) and mortality amognth the eldery.
The Is:
- instability - falls
- immobility
- intellectual (cognitive) impairment
- incotinence (urinary or faecal)
Mnemonic - all Im or In
Some also now add iatrogenic for polypharmacy to this list
Osteoperosis:
- Define Osteoperosis and Osteopenia
- What scan is used to diagnose Osteoperosis and what score is used as the cut off for each condition?
- Z score vs T score?
- Risk factors - 10 things - including a protective medication used to treat breast cancer
- 4 groups that NICE reccomends assessing for osteoperosis?
- How are people assessed?
- Who is bypasses this screening?
Osteoporosis involves a significant reduction in bone density. Osteopenia refers to a less severe decrease in bone density. Reduced bone density makes the bones weaker and prone to fractures.
The World Health Organization (WHO) provide definitions based on the T-score of the femoral neck, measured on a DEXA scan. The T-score is the number of standard deviations the patient is from an average healthy young adult. A T-score of -1 means the bone mineral density is 1 standard deviation below the average for healthy young adults.
Osteopenia - -1 to -2.5
Osteoporosis - Less than -2.5
Bone mineral density (BMD) is measured using a DEXA scan (dual-energy x-ray absorptiometry). DEXA scans are a type of x-ray that measures how much radiation is absorbed by the bones, indicating how dense the bone is. The bone mineral density can be measured anywhere on the skeleton, but the femoral neck reading is most important.
Bone density can be represented as a Z-score or T-score. The Z-score is the number of standard deviations the patient is from the average for their age, sex and ethnicity. The T-score is the number of standard deviations the patient is from an average healthy young adult. The T-score is used to make the diagnosis.
T is before Z so T is for young health, Z is fot actual age (older)
Risk Factors
Older age
Post-menopausal women
Reduced mobility and activity
Low BMI (under 19 kg/m2)
Low calcium or vitamin D intake
Alcohol and smoking
Personal or family history of fractures
Chronic diseases (e.g., chronic kidney disease, hyperthyroidism and rheumatoid arthritis)
Long-term corticosteroids (e.g., 7.5mg or more of prednisolone daily for longer than 3 months)
Certain medications (e.g., SSRIs, PPIs, anti-epileptics and anti-oestrogens)
TOM TIP: Post-menopausal women are an important group where osteoporosis should be considered. Oestrogen is protective against osteoporosis but drops significantly after menopause. Hormone replacement therapy (HRT) is protective against osteoporosis. Tamoxifen is a selective oestrogen receptor modulator (SERM) used to treat breast cancer. It blocks oestrogen receptors in breast tissue but stimulates oestrogen receptors in the uterus and bones. It helps prevent osteoporosis but increases the risk of endometrial cancer. Raloxifene is a SERM used to treat osteoporosis (but not breast cancer in the UK).
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The NICE clinical knowledge summaries (April 2023) recommend assessing:
Anyone on long-term oral corticosteroids or with a previous fragility fracture
Anyone 50 and over with risk factors
All women 65 and over
All men 75 and over
The 10-year risk of a major osteoporotic fracture and a hip fracture can be calculated using either:
QFracture tool (preferred by NICE)
FRAX tool (NICE say this may underestimate the risk in some patients - but remember made in sheffield).
Patients are categorised as low, intermediate or high risk based on the risk calculator. For QFracture, this is based on the percentage, and patients above 10% are considered for a DEXA scan. For FRAX, this is based on the NOGG guideline chart (linked to on the online FRAX tool), which advises whether to arrange a DEXA scan or start treatment.
These suggestions do not apply to specific groups. For example, NICE CKS (April 2023) suggest:
A DEXA may be arranged without calculating the risk in patients over 50 with a fragility fracture
Treatment may be started without a DEXA in patients with a vertebral fracture
Osteoperosis 2: Management?
- Step One?
- Step Two?
- First line - when is medical management started and what is used?
- What is their mechanism of action and name two key side effects?
- How long does this treatment window last?
- What other options are there and how do they work? 3 to learn
The first step is to address reversible risk factors. For example, increase physical activity, maintain a healthy weight, stop smoking and reduce alcohol consumption.
The second step is to address insufficient intake of calcium (less than 700mg per day) and inadequate vitamin D (e.g., limited sun exposure) with additional:
Calcium (at least 1000mg)
Vitamin D (400-800 IU)
Bisphosphonates are the first-line treatment for osteoporosis. They are recommended for patients with osteoporosis based on a DEXA scan - T score -2.5. They are considered in patients on long-term steroids. They work by interfering with the way osteoclasts attach to bone, reducing their activity and the reabsorption of bone. Me - Bisphosphonates attach to hydroxyapatite binding sites on bony surfaces, especially surfaces undergoing active resorption. When osteoclasts begin to resorb bone that is impregnated with bisphosphonate, the bisphosphonate released during resorption impairs the ability of the osteoclasts to resorb the bone. They also promote the actions of osteoblasts but that is less significant
Bisphosphonates have some important side effects:
Reflux and oesophageal erosions
Atypical fractures (e.g., atypical femoral fractures)
Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
Osteonecrosis of the external auditory canal
Oral bisphosphonates are taken on an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.
Examples of bisphosphonates are:
Alendronate 70 mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zoledronic acid 5 mg once yearly (intravenous)
The NICE CKS (2023) recommend reassessing treatment with bisphosphonates after 3-5 years. They suggest a repeat DEXA scan and stopping treatment if the T-score is more than -2.5. Treatment is continued in high-risk patients. A TREATMENT HOLIDAY
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Other specialist options for treating osteoporosis (where bisphosphonates are not suitable) include:
Denosumab (a monoclonal antibody that targets RANK lingand) - RANKL is produced by osteoblasts (the cells that build bone) and binds to its receptor RANK on the surface of osteoclast precursors, which stimulates these precursors to mature into fully functional osteoclasts. As such Desomab also inibits osteoclast function.
Romosozumab (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation)
Teriparatide (acts as parathyroid hormone) - dont get because PTH fires in low calcium and causes increase bone resorbtion, increased vitmain D. This is in parathyroid hormone - continuous high levels promote bone reosbtion but pulsaltile low doses given as teripartide actually promote bone formation.
Hip Fractures:
- two major risk factors for hip fracture
- two categories of hip fractures
Sidenote - If not sure on the basic anatomy of the NOF check the ZTF website.
- describe the blood supply to the head of the femour. How does this affect the management of intracapsular fractures?
- hemiathroplasty vs total hip replacement?
- management of extracapsular fractures?
- other features of management?
Hip fractures are an important topic in trauma and orthopaedics. They are common and lead to significant morbidity and mortality. The 30-day mortality is 5-10%. Half of patients become less independent after a hip fracture. Due to the morbidity and mortality with hip fractures, they are generally prioritised on the trauma list with the aim to perform surgery within 48 hours.
Increasing age and osteoporosis are major risk factors for hip fractures. Females are affected more often than males.
Hip fractures can be categorised into:
Intra-capsular fractures
Extra-capsular fractures
The capsule of the hip joint is a strong fibrous structure. It attaches to the rim of the acetabulum on the pelvis and the intertrochanteric line on the femur. It surrounds the neck and head of the femur.
The head of the femur has a retrograde blood supply. The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line. Branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head. They provide the only blood supply to the femoral head. A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head, leading to avascular necrosis.
Therefore, patients with a displaced intra-capsular fracture need to have the femoral head replaced with a hemiarthroplasty or total hip replacement. Non-displaced intra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral health without avascular necrosis occurring. They can be treated with internal fixation (e.g., with screws) to hold the femoral head in place while the fracture heals.
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Hemiarthroplasty involves replacing the head of the femur but leaving the acetabulum (socket) in place. Cement is used to hold the stem of the prosthesis in the shaft of the femur. This is generally offered to patients who have limited mobility or significant co-morbidities.
Total hip replacement involves replacing both the head of the femur and the socket. This is generally offered to patients who can walk independently and are fit for surgery.
Intertrochanteric fractures - dynamic hip screw
subtrochanteric fractures - intermedullary nail
I wouldnt worry too much about all this - if all you can remember is that displaced (seperated) intercapsular means need to replace the head.
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Other features of management:
The NICE guidelines (updated 2017) say that surgery should be carried out either the same day or the day after the patient is admitted (within 48 hours).
VTE prophalaxis - low molecular weight heparin
Appropriate Analgesia - The operation should allow the patient to weight bear straight away. This allows the physiotherapists to start mobilisation and rehabilitation as soon as possible after the operation. Post-operative analgesia is important to encourage the patient to mobilise as quickly as possible.
3 functions of Parathyroid hormone?
Parathyroid hormone increases serum calcium by:
1. PTH stimulates osteoclast activity in the bone causing increased resorption of calcium from the bone into the blood
2. PTH stimulates the kidneys to increase the reabsorption of calcium (and decrease phosphate reabsorption) so that less calcium is excreted in the urine
3. PTH stimualtes the kidneys to convert vitamin D3/ (25-hydroxy vitamin D) into calcitriol (1 25-dihydroxy vitamin D3). Calcitriol increase the absorption of calcium from food in the intestines - therefore PTH indirectly increase calcium absorption in the intestines
Hip Fractures 2:
- presentation of a hip fracture? Including the 3 signs on examination?
- Ix for hip fracture?
- what Xray sign is seen in fractured NOF?
The typical scenario is an older patient (over 60) who has fallen, presenting with:
Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted and externally rotated leg
Not for learning but good to note - An essential part of assessing patients with a new hip fracture is to determine any other acute illnesses. There is often a good reason for them to fall and break a hip. They may also be suffering with: Anaemia, Electrolyte imbalances, Arrhythmias, Heart failure, Myocardial infarction, Stroke and Urinary or chest infection
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X-rays are the initial investigation of choice. Two views are essential, as a single view can miss the fracture. Anterior-to-posterior (AP) and lateral views are standard.
MRI or CT scanning may be used where the x-ray is negative, but a fracture is still suspected.
** Disruption of Shenton’s line is a key sign of a fractured neck of femur (NOF). ** Shenton’s line can be seen on an AP x-ray of the hip. It is one continuous curving line formed by the medial border of the femoral neck and continues to the inferior border of the superior pubic ramus.
