Geriatrics & Palliative Flashcards
What is Acute Confusional state ??
aka Delirium or Acute Organic Brain synd. AFFECTS upto 30% of elderly pts. admitted in the hospital
RF-
- > 65yrs old. - Dementia
- Significant injury (eg. Hip #)
- Frailty or Multi-morbidity
- Polypharmacy
Rx. strategy in Alzheimer’s pts. ??
Non-pharmacological:
- Mild- Moderate dementia: Cognitive Stimulation Therapy
- Grp. Reminiscence Therapy & Cognitive Rehabilitation
Pharmacological Therapy
Non-Cognitive c/f management
- Antipsychotics : used for pts. at risk of harming themselves/ others or when agitation, hallucinations or delusions are causing severe distress
MCC of Dementia in the UK ??
Alzheimer’s disease - progressive degenerative brain disease
- followed by Vascular & Lewy Body dementia
- FTLD (3rd MC cause)
Rx. of Acute Confusional State ??
Treat the underlying cause
- 1st line sedative: HALOPERIDOL or Olanzapine
- Parkinson’s pts. : Atypical anti-psychotics - Quetiapine & Clozapine
What are the ppt. event & Features of Delirium ??
- Infection (UTI)
- Metabolic (Hyper Ca2+, Hypo/Hyper- glycaemia, Dehydration
- Change in environment
- Significant systemic condition
- Severe pain. - Constipation
FEATURES - Memory disturbed (Short term> Long term)
- Disoriented, Poor attention
- Mood Changed, Disturbed sleep
- Visual hallucinations
Pharmacological Rx. for Alzheimer’s disease ??
Mild to moderate dementia
- 1st line: ACh-esterase inhibitors- Donepezil, Galantamine, Rivastigmine
Memantine
- Moderate dementia + intolerant or CI of 1st line Rx.
- Add on to 1st line Rx. for Moderate or Severe cases
- Monotherapy in SEVERE cases
Relative CI of Donepezil ??
BRADYCARDIA
[s/e: Insomnia]
Risk Factors of Alzheimer’s disease ??
- Increasing age, Family Hx.
- Autosomal D inheritance (5% cases)
- Apoprotein E allele E4: encodes a cholesterol transport protein
- Caucasians
- Down’s synd.
What mutations are seen in the A D variant of Alzheimer’s disease ??
- Amyloid precursor protein (Chr. 21)
- Presenilin 1 (Chr. 14)
- Presenilin 2 (Chr. 1)
What is Dementia ??
Umbrella term for loss of memory & other thinking abilities, which is severe enough to interfere with daily life
Pathological changes seen in Alzheimer’s disease ??
MACROSCOPIC
- Widespread Cerebral atrophy (Cortex & Hippocampus)
MICROSCOPIC
- Cortical plaques due to Type-A-Beta-amyloid protein deposition & Intraneural Neurofibrillary tangles caused by abnormal aggragation of TAU protein
- Hyperphosphorylation of Tau protein
BIOCHEMICAL
- Ascending Forebrain projection damage ==> ACh deficit
Name the following about dementia
- Assessment tools for Non- specialists ??
- Assessment tools NOT recommended by NICE for Non-specialists ??
- 10- Point Cognitive Screener (10-CS)
- 6-Item Cognitive Impairment Test
NOT recommended- - Abbreviated Mental Score Test
- General Practitioner Assessment of Cognition (GPCOG)
- Mini-mental Score Test (MMSE) : a score of < 24/ 30 suggests dementia
What are Neurofibrillary tangles ??
Paired Helical filaments, partly made of a protein called Tau
- Tau interacts with Tubulin to stabilise microtubules & promote Tubulin assembly into Microtubules
- in A D, tau are Hyperphosphorylated, impairing its function
Rx. of Dementia ??
Primary Care
- Blood screening (to rule out Reversible causes- FBC, U&E, LFTs, Ca2+, Glucose, ESR, CRP, TFTs, Vit.-B12, Folate)
- Pts. are now commonly referred to Old-age Psychiatrists in Memory clinic
SECONDARY Care
- Neuro-imaging (to exclude secondary causes- SDH, NPH)
What are the factors that favours DELIRIUM over dementia ??
- Impaired consciousness
- Fluctuation of symptoms: Worse at night, periods of normalcy
- Abnormal perception (eg. Illusions, hallucinations)
- Agitation, fear
- Delusions
What are the types of Fronto-temporal Lobar Degeneration (FTLD) ??
FTLD is the 3rd MC type of Cortical dementia after Alzheimer’s & Lewy Body dementia
- Fronto-temporal Dementia
- Progressive Non-fluent Aphasia (Chr. Prograssive Aphasia, CPA)
- Semantic Dementia
What are the treatable causes of Dementia ??
- Hypothyroidism, Addison’s
- B12/ Folate/ Thiamine deficiency
- Syphilis
- Brain tumour
- NPH
- SDH (Sub-dural Haematoma)
- Depression
- Chr. Drug use (eg.- Alcohol, Barbiturates)
Causes of Dementia ??
Common causes
- Alzheimer’s disease
- CerebroVascular disease: Multi-infarct dementia (10-20%) cases
- Lewy Body Dementia (10-20%)
RARER Causes (5% cases)
- Huntington’s
- CJD
- Pick’s dementia
- HIV (50% of AIDS pts.)
What are the common features of FTLD ??
- Onset < 65 yrs
- Insidious onset
- Relatively Preserved Memory & Visuo-spacial skills
- Personality change & Social conduct problems
What is Pick’s Dementia ??
MC type of FTLD; Personality change & Impaired Social Conduct
- Hyperorality, Disinhibition, Increased Appetite, Perverse behaviour
Rx-
- AChE inhibitors or Memantine but NICE do NOT recommend this
Features/ Changes seen in Pick’s dementia ??
Macroscopic
- Frontal & Temporal lobe atrophy
Microscopic
- Pick bodies: Spherical aggregations of Tau proteins (Silver-staining)
- Gliosis
- Neurofibrillary Tangles
- Senile Plaques
CT
- “Focal gyral atrophy with a knife-blade appearance”
What is
- CPA (Chr. Progressive Aphasia)
- Semantic Dementia
CPA
- Non-fluent speech
- Short utterances that are Agrammatic.
- Comprehension is relatively preserved
Semantic Dementia
- Fluent progressive aphasia
- Fluent speech but Empty & conveys little meaning.
- Short term memory better than Long term memory (opposite in Alzheimer’s)
What is Lewy Body Dementia ??
Lewy body: Alpha-synuclein cytoplasmic inclusion bodies deposition in
- Substantia nigra
- Paralimbic area
- Neocortical area
Features of Lewy Body Dementia ??
Progresive Cognitive Impairment
- Attention & Executive function impairment rather than memory impairment
- Fluctuating COGNITION
- Develops BEFORE Parkinsonism
Parkinsonism
VISUAL Hallucinations (delusions & non- visual hallucinations may also be seen)
Dx. & Rx. of Lewy Body Dementia ??
Clinical Dx.
Single Photon Emission CT which is commercially known as DaT scan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-1 FP-CIT) is used as the radioisotope
- Sensitivity: 90%
- Specificity: 100%
Rx. of Lewy Body Dementia ??
- AChE inhibitor (Donepezil, Rivastigmine) & Memantine
- Neuroleptics are AVOIDED as they may develop Irreversible Parkinsonism [Pt. can deteriorate following the introduction of an antipsychotic]
What are Pressure ulcers & list a few predisposing factors ??
Ulcers develops in part of body which cannot be moved due to Illness, Paralysis, advancing age; typical over bony prominences (heel, sacrum)
- Malnourishment
- Lack of mobility
- Incontinence
- Pain (leads to a reduction in mobility)
What is Waterlow score ??
Widely used to screen for pts. who are at risk of developing pressure areas. It includes
- BMI
- Nutritional status
- Skin type
- Continence
Rx. of Pressure sores ??
MOIST Wound environment encourages ulcer healing- Hydrocolloid dressing & Hydrogels help this
- Routine wound swabs are NOT recommended
- Consider referral to Tissue Viability Nurse
- Surgical debridement in selected cases
Features & Causes of Vascular Dementia ??
A group of synd. of COGNITIVE impairment caused by different mechanisms causing ischaemia/ haemorrhage secondary to cerebrovascular disease
- Stroke doubles the risk of developing dementia
- Increases with age
What are the types & risk factors of Vascular dementia ??
Stroke related VD: Multi/ Single infarct dementia
Subcortical VD: caused by Small vessel disease
Mixed Dementia: Both VD + Alzheimer’s are present
RISK Factors
- H/o Stroke or TIA; CAD
- Atrial Fibrillation
- DM, HTN, Hyperlipidaemia
- Smoking & Obesity
- FHx of Stroke or CVS disease
Which is the inherited cause of Vascular dementia ??
CADASIL (Cerebral A D Arteriopathy with Subcortical infarcts & Leukoencephalopathy)
Features of Vascular dementia ??
Presents with Several months or several years of a history of a sudden or Stepwise Deterioration of cognitive function
- FND/ abnormalities eg.- Visual disturbance, Sensory or Motor c/f
- Attention & Conc. difficulty
- Seizures
- Memory, Speech, GAIT disturbance
- Emotional disturbance
How is Vascular Dementia diagnosed ??
- Comprehensive history & GPE
- Formal Screening for Cognitive impairment
- Medication review
- MRI scan
Dx.- NINDS-AIREN criteria
What is NINDS-AIREN criteria ??
Used for the dx. of Vascular D
- Cognitive decline + interferes with daily living activity which is NOT due to secondary effects of CVA (Clinical examination & Neuropsychology tests used)
- Cerebrovascular disease: defined by neurological signs &/or brain imaging
- Relation b/w the above 2 disorders inferred by
—–Dementia onset in < 3 months after a stroke
—–Abrupt deterioration of Cognitive func.
—–Fluctuating, stepwise progression of cognitive deficits
Rx. of Vascular Dementia ??
Drug Rx.
- No specific Rx. is approved for Cognitive symptoms
- AChE inhibitors or Memantine: VD + Alzheimer’s/ Parkinson’s dementia/ Lewy body dementia suspected
- Aspirin & Statins use are baseless
Non-pharmacological
- Cognitive stimulation programmes, Multisensory stimulation, Music & art therapy, Animal assisted therapy
Rx. for Agitation & Confusion ??
Underlying cause should be treated (eg. Hyper Ca2+, Infection, Urinary retention & Medication)
- 1st line: HALOPERIDOL
- 2nd line: Chlorpromazine, Levomepromazine
- Terminal phase of illness: Treat with MIDAZOLAM
General principles followed for the Rx. of PAIN in Palliative care ??
When Starting Rx.
- Regular Oral Modified release (MR) or Immediate release Morphine + Oral Immediate release Morphine (for Breakthrough pain)
- If no co-morbidities; use 20-30 mg of MR a day + 5 mg Morphine for breakthrough pain (eg. 15mg Morphine- BD + 5mg oral Morphine solution as required)
- Oral MR Morphine prferred over Transdermal patch
- Laxatives are started for all pts. initiated on Strong Opioids
- Antiemetics (if Nausea persists)
- Dose adjustment (if Drowsiness persists)
How much is the dose of Morphine for Breakthrough pain ??
1/6 th of the daily Morphine dosage
Opioid of choice in the following
- Mild to moderate Renal disease ??
- Severe Renal impairment ??
- OXYCODONE preferred over Morphine
- Alfentanil, Buprenorphine & Fentanyl (eGFR < 30 ml/min) are preferred
Rx. for Intractable Hiccups ??
- CHLORPROMAZINE
- Haloperidol & Gabapentin can also be used
- DEXAMETHASONE (particularly if there are Hepatic lesions)
Pain Rx. in Metastatic Bone disease ??
Strong Opioids > Bisphosphonates > Radiotherapy, Beta-emitting Radioisotope (Strontium 89therapy)
- Strong Opioids have the lowest NNT for pain & provides quick relief in contrast to the other 2
- Referred to Oncologist if considering further Rx like Radiotherapy
- 30- 50% dose increment is done if at all the Opioid dose is increased
- Denosumab can also be used
Conversions b/w Opioids ??
- Oral Codeine or Tramadol to Oral Morphine => Divide by 10
- Oral Morphine to Oral Oxycodone => Divide by 1.5 to 2
- Oral M to SC M => Divide by 2
- Oral M to SC DiaM => Divide by 3
- Oral Oxy to SC DiaM=> Divide by 1.5
Conversion factors for Transdermal patches ??
12 ug of T-fentanyl => 30mg Oral M
10 ug T-Buprenorphine => 24mg Oral M
Oxycodone advantage & disadvantage ??
Less sedation, vomiting & pruritis than M but MORE Constipation
Which are the Transient & Persistent S/E of Opioids ??
Transient: Nausea & Drowsiness
Persistent: Constipation
How to treat Secretions in Palliative pts. ??
Avoid Fluid overload- stop IV or SC fluids
- Educate the family that- pt. is NOT troubled by secretions
- 1st line: Hyoscine hydrobromide or Hyoscine butylbromide
- H butylbromide may be less sedative than H hydrobromide
- Glycopyrronium bromide may also be used
Indications & Types of Syringe drivers ??
Considered when a palliative pt. is UNABLE to take Oral medication due to Nausea, Dysphagia, Intestinal obstruction, weakness or coma
2 Main Types
- Graseby MS16A (Blue): delivery rate is given in ‘mm/hr’
- Greseby MS26 (Green): delivery rate is given in ‘mm/24 hrs’
Which drugs are compatible with Water for injection ??
Drug + 0.9% NaCl
- Granisetron
- Ondansetron
- Ketamine
- Ketorolac
- Octreotide
Name the commonly used drugs for the following-
- N & V ??
- Agitation & Restlessness ??
- Pain ??
- Cyclizine, Levomepromazine, Haloperidol, Metoclipramide
- Midazolam, Haloperidol, Levomepromazine
- Diamorphine is the preferred opioid
DoC for the following-
- Agitation ??
- Acute psychotic episode ??
- Haloperidol
- Risperidone
Morphine Slow Release dose is increased ONLY after the Top-Ups dose has been titrated to the pt needs so the dose can be ascertained(Initial increase in Slow release can lead to side effects)
Parkinson’s + Motor symptoms well controlled + Visual hallucinations & Delusions
Rx. ??
Atypical antipsychotics (eg. Quetiapine)
- Typical antipsychotics are DA agonists => worsens Parkinson/s
Acute methods to reduce Intracerebral pressure ??
Hyperventilation & IV Mannitol
What is Progressive Supranuclear Palsy ??
It is a Parkinson’s plus syndrom
- Falls seen very shortly after the onset of symptoms
- DYSPHAGIA
- Loss of Vertical gaze (Supranuclear gaze palsy)
- Decreased verbal fluency
- Poor response to Levodopa therapy
- Symmetrical (Proximal»_space; Distal) Rigidity
Autonomic dysfunction is uncommon
