geriatrics_20231205142302 Flashcards
What is dementia?
A progressive decline in the ability to remember, think, and make decisions.
What is the most common type of dementia?
Alzheimer’s
What type of dementia is associated with halluciations?
Lewy body dementia
What kind of decline does vascular dementia show?
Stepwise decline
What is the pathophysiology of lew body dementia?
Lewy bodies build up in the substantia nigra, paralimbic and neocortical areas
What are lewy bodies?
Alpha-synuclein cytoplasmic inclusions
How does lewy body dementia differ from Parkinson’s?
Dementia usually occurs before any parkinsonism
What are the features of lewy body dementia?
Parkinsonism Visual hallucinations Progressive cognitive impairmentREM sleep behavioural disturbance
How does cognition change day to day in lewy body dementia?
Cognition is fluctuating
What investigations can be carried out to help diagnose lewy body dementia?
DaTscan
Why may a DaTscan be performed in someone with suspected lewy body?
To differentiate from Alzheimer’s
What is the first line medical management of lewy body dementia?
Cholinesterase inhibitor
What is the first line management of lewy body dementia?
Supportive treatment
What kind of medications should be avoided in patients with lewy body dementia?
Antipsychotic medications
Trisomy 21 leads to an increased risk of which type of dementia?
Alzheimer’s
What are the risk factors of developing Alzheimer’s?
Increasing age
Family history
Genetics
Down’s syndrome
Caucasian ethnicity
What are the histopathological changes seen in Alzheimer’s disease?
Neurofibrillary triangles Beta amyloid plaques Cortical atrophy
What is a potentially reversible cause of dementia?
Normal pressure hydrocephalus
What is the first line medical management of Alzheimer’s?
Cholinesterase inhibitors
What is the second line medical management of Alzheimer’s?
Memantine
What drug class is memantine?
NMDA receptor antagonist
What other management options should be offered to people with Alzheimer’s?
Group therapies - cognitive stimulation therapy Activities to promote wellbeing
What is vascular dementia caused by?
Vascular dementia is secondary to cerebrovascular disease
What are the risk factors for vascular dementia?
Hypertension AFDiabetesHistory of stroke History of TIA Smoking ObesityFamily history of stroke or TIA
What are the symptoms of vascular dementia?
Focal neurological deficits Memory disturbanceSpeech disturbance Gait disturbanceDifficulty with attention and concentration
What criteria is used for the diagnosis of vascular dementia?
NINDS-AIREN criteria
What is the NINDS-AIREN criteria?
A relationship between cognitive decline and cerebrovascular disease:- Onset of cognitive decline within 3 months of a cerebrovascular event- An abrupt decline in cognitive function - Fluctuating, stepwise deterioration of cognitive function
What is the mainstay of treatment for patients with vascular dementia?
Prevention of another cerebrovascular eventSymptomatic treatment
What secondary prevention medication should vascular dementia patients be on?
Antiplatelet therapy - aspirin or clopidogrel
What other medications can be used in patients with Lewy body dementia?
Levodopa, dopamine receptor antagonists
What investigations can be used to diagnose Alzheimer’s?
CT head Mini mental state exam
What cognitive assessments can be used to assess cognition?
AMT - abbreviated mental test
Addenbrooke’s cognitive examination (ACE-III)
MoCA test
General Practitioner assessment of cognition (GPCOG)
Give 3 risk factors for lewy body dementia.
> 60 years Male Family history of Parkinson’s or lewy body dementia
What investigations can be carried out in the diagnosis of vascular dementia?
MMSECarotid USSCT headMRI head
What is the preferred investigation for diagnosing vascular dementia?
MRI head
What is psuedo-dementia?
A decline in cognitive function that can seen in older adults with depression
How does pseudodementia present?
Patients will often answer ‘don’t know’Short duration of dementia Equal effect on long term and short term memory Amnesia concerning specific events
Give an example of a cholinesterase inhibitor.
Donepezil
On what side does ischaemia to the cerebellum cause symptoms?
Ipsilateral side
Where does the PICA supply?
Inferior cerebellum
What is the gold standard investigation for stroke?
Diffusion weighted MRI
What features are caused by an anterior inferior cerebellar artery infarct?
Ipsilateral deafness and facial paralysisSudden onset of vertigo and vomiting
What features are caused by a posterior inferior cerebellar artery infarct?
Ipsilateral facial pain and temperature lossContralateral limb/torso pain and temperature lossAtaxia and nystagmus
What are the risk factors for haemorrhagic stroke?
Anticoagulation therapy AgeHypertension Arteriovenous malformation
What are the risk factors for ischaemic stroke?
AgeHypertension Smoking Hyperlipidaemia DiabetesAtrial fibrillationHRTOral contraceptive
What symptoms are seen in a total anterior circulation infarct?
Unilateral hemiparesis, or unilateral hemisensory loss of upper or lower limb Homonymous hemianopia Higher cognitive dysfunction e.g dyphasia
Which limbs are more typically affected in anterior circulation infarcts?
Lower limbs
Which limbs are more typically affected in middle cerebral artery infarcts?
Upper limbs
What kind of symptoms would be seen with an ophthalmic artery stroke?
Amaurosis fugax
What is the first line investigation for a suspected stroke?
Non-contrast CT head
What is the difference between stroke and Bell’s palsy?
Strokes are forehead sparing, whereas Bell’s palsy involves the forehead
What is the Bamford classification?
A system of classifying and diagnosing ischaemic stroke
What is the Bamford classification of a total anterior circulation infarct?
All three symptoms: - Homonymous hemianopia- Unilateral weakness or sensory deficit of the face, arm and leg- Higher cerebral dysfunction
What is the Bamford classification of a partial anterior circulation infarct?
Two out of three symptoms: - Homonymous hemianopia- Unilateral weakness or sensory deficit of the face, arm and leg- Higher cerebral dysfunction
What is the Bamford classification of a posterior circulation stroke?
One of the following symptoms?- Cranial nerve palsy and contralateral motor/sensory deficit- Cerebellar dysfunction - Bilateral sensory or motor deficit- Conjugate eye movement disorder- Isolated homonymous hemianopia
What is the Bamford classification of a lacunar stroke?
One of the following symptoms:- Pure sensory stroke - Pure motor stroke - Sensori-motor stroke- Ataxic hemiparesis
What is the initial management of an ischaemic stroke?
300mg aspirin Thrombolysis if presented within 4.5 hours Thrombectomy if between 4.5-6 hours
What drug is used in thrombolysis?
Alteplase
What secondary prevention will be given after an ischaemic stroke?
Clopidogrel 75mg dailyStatin Anti hypertensivesCarotid endarterectomy
What is the initial management of a haemorrhagic stroke?
Aim for BP 140/90Stop anticoagulants and antithromboticsReverse any anticoagulationRefer to neurosurgery
What tools can be used to assess stroke?
FASTROSIERABCD2
What is a TIA?
A sudden onset of a focal neurological deficit (of vascular origin) that resolves in 24 hours
What are crescendo TIAs?
More than 1 TIA in 7 daysTIAs that are increasing in frequency and severity
What is the definition of a stroke?
Sudden onset of a focal neurological deficit of vascular cause, with symptoms lasting more than 24 hours.
What drugs are likely to cause osteoporosis?
Corticosteroids
What risk score can be used to calculate risk of a fracture?
FRAX
What are the risk factors for osteoporosis?
SHATTERED FAMILY Steroid useHyperthroidism, hyperparathyroidismAlcohol and smoking Thin Testosterone deficiency Early menopause Renal or liver failureErosive or inflammatory bone diseaseDiabetesFamily history
What investigations can be used to diagnose osteoporosis?
DEXA scan LFTsTFTsCRPSerum calcium Bone profile
What will ALP, PTH, calcium and phosphate levels be in a patient with osteoporosis?
All normal
What is the first line pharmacological therapy for osteoporosis?
Bisphosphonates
What types of drugs can increase the risk of osteoporosis?
CorticosteroidsHeparin
What factors is a Z score adjusted for?
Age, sex, ethnicity
What is a FRAX score?
The 10 year risk of a fracture in an adult aged 40-90
What is a T score?
Bone mineral density, compared to the average healthy young person
What T score is diagnostic of osteoporosis?
<-2.5
What is a normal T score?
> -1
What T score is diagnostic of osteopenia?
Between -1 and -2.5
What is the gold standard investigation for osteoporosis?
DEXA scan
What other investigations are carried out in someone with suspected osteoporosis?
Bone profile
Vitamin D level
TFTs
Urinary free cortisol
Testosterone
Bence jones protein
How should bisphosphonates be taken?
Patients should sit up for 30 minutes after taking, and should take with a large glass of water
What are the second line medications for patients with osteoporosis?
Denosumab HRTRaloxetine - used in post menopausal women
When are bisphosphonates contraindicated?
Reduced GFRHypocalcaemia Oesophageal abnormalitiesPregnancy/breastfeeding
What is the classic triad of Parkinson’s?
BradykinesiaResting tremorRigidity
What is the pathophysiology of Parkinson’s?
A reduction in the amount of dopaminergic neurons in the substantia nigra
What are some other common symptoms of Parkinson’s?
Stooped posture
Facial masking
Reduced arm swing
Shuffling gait
Small handwriting
Difficulty initiating movement
What kind of tremor can be seen in Parkinson’s?
Pill rolling tremor
What is the difference between Parkinson’s and benign essential tremor?
Parkinson’s- Worsens with rest- Asymmetrical- Improves with intentional movement - No change with alcohol Benign essential tremor - Improves with rest- Symmetrical - Worsens with intentional movement - Improves with alcohol
What are the differential diagnoses of Parkinson’s?
Lewy body dementia Benign essential tremor Drug-induced Parkinsonism Progressive supranuclear palsyMultiple system atrophy
What is the first line treatment of Parkinson’s?
Levodopa/carbidopa
What is levodopa?
L-dopa is a precursor to dopamine
What is carbidopa?
Carbidopa prevents levodopa from being broken down before reaching the brain - leads to a lower dose of levodopa needed, and fewer side effects
What is the second line treatment of Parkinson’s?
Dopamine agonists, COMT inhibitors, MAO-B inhibitors
When might a dopamine agonist be considered for initial therapy?
To delay starting levodopa, as levodopa’s effectiveness reduces overtime
What are the signs of multiple system atrophy?
Parkinsonism Autonomic dysfunctionCerebellar signs
What is multiple system atrophy?
A rare neurodegenerative disorder that causes gradual damage to neurons
What are the common side effects of levodopa?
Dry mouth
Palpitations
Psychosis
Anorexia
Postural hypotension
Give an example of a dopamine receptor agonist.
Cabergoline
What medications are contraindicated in Parkinson’s?
Haloperidol - it promotes dopamine blockade
What medication can be used to sedate Parkinson’s patients?
Lorazepam
What is the most important side effect of dopamine agonists?
Impulsivity
What is delirium?
An acute, fluctuating mental status, with inattention, disorganised thinking and altertered levels of consciousness
What are the four features of delirium?
A change in cognition A disturbance in attention Disturbance develops over a short period of timeEvidence of coinciding physiological changes
What are the three types of delirium?
Hyperactive delirium Hypoactive delirium Mixed delirium
What are the signs of hyperactive delirium?
RestlessnessAgitation Inappropriate behaviour Hallucinations
What are the signs of hypoactive delirium?
Lack of interest Lethargy Reduced motor activityIncoherent speech
What are the signs of mixed delirium?
A mix of hyperactive and hypoactive signs
What are the differentials of delirium?
Dementia Pain Stroke Head traumaPsychosis Depression
What are the risk factors for delirium?
Older ageDementia or cognitive impairment Decreased oral intake Visual or hearing impairment History of deliriumPolypharmacy Physical frailty
What are some common causes of delirium?
DELIRIUMSD - drugs and alcohol E - eyes, ears and emotional disturbance L - low output state I - Infection R - retention I - ictal (seizure activity)U - Under hydration/ under nutrition M - metabolic disorders S - subdural haematoma, sleep deprivation
What must be considered for a diagnosis of delirium?
Baseline cognitive and functional status to differentiate from dementia
What investigations can be carried out to find a cause of delirium?
FBC - rule out anaemia or infection U&EsUrinalysisCXRDrug levels in patients on certain drugs ECG ABGBlood cultureMMSEConfusion assessment method - screening/diagnostic tool for delirium
What drugs can cause delirium?
BenzodiazepinesAnalgesics e.g opioidsAnti-cholinergics
What is the primary treatment of delirium?
Treat the underlying cause
What drugs can be given to manage the delirium itself?
IM haloperidol (lorazepam in PD and lewy body dementia patients)
What assessment tool can be used to diagnose delirium?
Short-CAM (confusion assessment method)
What is the ICD-10 criteria for delirium?
Impairment of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of sleep wake cycle Emotional disturbances
What are the types of urinary incontinence?
Stress incontinence Urge incontinence Overflow incontinenceFunctional incontinenceMixed incontinence
What is stress incontinence?
Incontinence when intra-abdominal pressure is raised
What is urgency incontinence?
The sudden and involuntary loss of urine associated with the urge to urinate
What is overflow incontinence?
The leakage of small amounts of urine without warning
Why does overflow incontinence occur?
When the pressure of the bladder overcomes the pressure of the outlet structures - usually due to underactivity of the detrusor muscle, or extra pressure on the urinary outlet structures
What can put extra pressure on the urinary outlet structures?
BPHConstipation
What is functional incontinence?
The patient has the urge to pass urine, but is unable to access the necessary facilities
What are the causes of functional incontinence?
Sedating medications Alcohol Dementia
What are the risk factors for stress incontinence?
Childbirth Hysterectomy
What can trigger stress incontinence?
Laughing Coughing Physical activitySneezing
What are the risk factors for urge incontinence?
Recent or recurrent UTI High BMI SmokingCaffeine
What investigations are helpful in diagnosing urinary incontinence?
Questionnaires Bladder diary Cystometry - measures bladder pressure whilst voiding Cystogram - radiological image with contrastUrine dip MSU
What lifestyle advice can improve stress incontinence?
Pelvic floor exercises Avoiding alcohol and caffeineAvoiding excessive fluid intake
What is the surgical management of stress incontinence?
Incontinence pessaries - supports the base of the bladderUrethral bulking agents - injections into the area around the urethra to improve the sphincter’s ability to closeMid urethral sling procedure (gold standard)
What is the medical management of urge incontinence/ overactive bladder?
Anticholinergic medications - Oxybutynin - Tolterodine - Festerodine
What is the surgical management of urge incontinence?
Botox injections (to paralyse the detrusor)Sacral neuromodulation
Give 4 reversible causes of urinary incontinence.
UTI Type 2 diabetesDiuretics Delirium
What are the risk factors for constipation?
Increasing ageInactivityLow fibre dietMedications Low calorie intake Surgical proceduresFemale
What are the symptoms of constipation?
Passing stools < 3 times per weekDifficulty passing stools Sensation of incomplete evacuation - tenesmusAbdominal distension Abdominal mass in left or right lower quadrantsHaemorrhoids
What are the red flag features of constipation?
Weight lossDark stools Abdominal massLoss of appetite
What investigations would you perform for a constipated patient?
DREFBCU&ETFTsAbdominal XRColonoscopyBarium enema
What are the causes of constipation?
Dietary - low calorie, low fibreBehavioural - avoidance of defecation Electrolyte disturbanceDrugs - opiates, calcium channel blockers, antipsychoticsNeurological disordersEndocrine disordersColon disease - cancer, strictureAnal disease - fissure
What is the initial management of constipation?
Lifestyle advice
- Increase fibre
- - Increase calorie intake
- - Increase fluid intake
- - Regular exercise
What is the initial pharmacological management of constipation?
Bulk laxative - ispaghula husk - Methylcellulose
What other medications can be used to manage constipation?
Stool softeners - docusate sodiumOsmotic laxatives - lactulose, macrogolStimulant laxatives - senna
What other management options are there for constipation?
Enema if stool is impactedSuppositories
What type of stools does constipation usually present with?
Type 1 or 2Can be type 7 if there is overflow diarrhoea
What is a deprivation of liberty?
Article 5 states that everyone has the right liberty - no person should be deprived of that liberty unless in accordance with the law- Under a Deprivation of Liberty safeguard it is necessary and legal to deprive a person of their liberty
What are the key principles of the mental capacity act?
Capacity is assumed and needs to be proven otherwise
Enables people to make their own decisions
Prevents unwise decisions
Acts in the best interests of the patient
The least restrictive management option should always be chosen
What is Charles Bonnet syndrome?
Patients with visual loss will have hallucinations as the brain tries to fill in the missing picture. The patient is aware that the hallucinations aren’t real
What is BPPV?
Benign paroxysmal positional vertigo - sudden onset of vertigo following head movements
How does BPPV present?
Sudden onset vertigo after head movementsVertigo lasts 20-60 seconds Patients are asymptomatic between attacks
How is BPPV differentiated from labyrnithitis?
BPPV does not cause hearing loss
What is the cause of BPPV?
Calcium carbonate crystals called octonia become lodged in the semi circular canals. The normal flow of endolymph through the canals is distrupted.
What causes the crystals to become displaced?
Viral infection
Head trauma
Aging
Idiopathic
Where are the crystals most commonly displaced?
Posterior semicircular canal
How is BPPV diagnosed?
Dix-hallpike manoeuvre
How is the dix-hallpike manoeuvre performed?
Start with the patient sitting upright on a couch Turn the patient’s head to 45 degreesQuickly lower the patient backwards, with their head hanging off the back of the bedLook for nystagmusRepeat on the other side
What is the first line management of BPPV?
Epley manoeuvre
What else can be done to improve BPPV?
Brandt-Daroff exercises
What is involved in Brandt-Daroff exercises?
Involves sitting on the edge of a bed and lying sideways, from one side to the other
What is Meniere’s disease?
Recurrent episodes of vertigo, nausea, hearing loss, tinnitus and aural fullness
How does Meniere’s disease differ from acute labyrinthitis?
Symptoms are similar, but Meniere’s disease is recurrent whereas acute labyrinthitis occurs as one episode
What medication can be used for prophylaxis of menieres disease?
Betahistine
What medication an be used to treat acute attacks of menieres’s disease?
Prochlorperazine Antihistamines
What is the progression of hearing loss in meniere’s disease?
Fluctuated at first, with hearing loss associated with attacks of vertigo - Then becomes a more progressive and permenant sensorineural hearing loss
What is the pathophysiology of Meniere’s disease?
It is associated with excessive build up of endolymph in the labyrintyh of the inner ear, which increases pressure in the inner ear and disrupts signalling
What systems are involved in normal gait?
Neurological system - basal ganglia Musculoskeletal system Fine touch and proprioception
What are the risk factors for falls?
Lower limb muscle weaknessVision problems Balance problems Polypharmacy Incontinence >65 years old Fear of falling Depression Postural hypotension Psychoactive drugs Previous falls Cognitive impairment
What medications can cause postural hypotension?
Tamsulosin Beta-blockers Nitrates Diuretics Anticholinergic medications L-Dopa ACE inhibitors
What other medications are associated with falls?
Benzodiazepines Antipsychotics OpiatesAnticonvulsants Codeine Digoxin
What investigations are recommended in someone who has fallen?
Blood pressure Blood glucose Urine dip FBC U&ELFTs Bone profile X-ray of chestX-ray of affected limbs CT head Echocardiogram
Which patients should be referred for a multidisciplinary assessment?
> 2 falls in a year A fall that requires medical treatment Failure to complete Turn 180 or Timed up and go test
What is the length of a normal timed up and go test?
10 seconds or less
What is the turn 180 test?
Patient should be able to get up from a chair, walk 10 feet, turn around and walk back within 20 seconds
What tests are used to assess the risk of falls?
Turn 180 test Timed up and go test
What management options can help prevent future falls?
Strength and balance training Home hazard assessment Medication review Vision assessment
What is mild hypothermia?
32-35 degrees body temperature
What is moderate or severe hypothermia?
<32 degrees body temperature
What are the causes of hypotheramia in the elderly?
Exposure to cold in the environment Inadequate insulation in the operating theatreCardiopulmonary bypass
What are the risk factors for hypothermia?
General anaesthesia Substance abuse Hypothyroidism Impaired mental status HomelessnessExtremes of age
What are the signs of hypothermia?
Shivering Cold and pale skin Slurred speech Tachypnoea Respiratory depression Bradycardia Confusion
What are the investigations for hypothermia?
12 lead ECG Temperature FBC Blood glucose ABG Coagulation factors CXR
What would be seen on an ECG in hypothermia?
Acute ST elevation J wave
What might be seen on bloods in someone with hypothermia?
Elevated haemoglobin and haematocrit Hypokalaemia
What is the initial management of hypothermia?
Remove patient from environment Remove wet blankets or clothing Warm the body with blankets Secure the airway and monitor breathing Warm IV fluids or passing warm air over the patient
What is the definition of hyperthermia?
Body temperature of more than 40 degrees
What features of the elderly make them more susceptible to hyperthermia?
Reduced cardiac output
Chronic volume depletion
Normal deficiencies in heat shock protein
What are the features of hyperthermia?
Agitation
Lethargy
Seizures
Hot dry skin
Elevated core body temperature
Intense thirst
Weakness
Syncope
Headache
Tachypnoea
Tachycardia
What are the risk factors for hyperthermia?
Age > 65 Pre-existing dehydration Obesity Environmental factorsDiabetesCardiovascular diseaseCongenital disordersDrug and alcohol misuseMedications - Diuretics - Beta blockers - Anticholinergics - Antidepressants - Antihistamines
What investigations should be performed in someone with hyperthermia?
FBC
LFTs
Renal function
Rectal temperature
Glucose
U&E
ABG
Creatinine Kinase
Urinalysis
ECG
What electrolyte abnormalities might be seen in hyperthermia?
Hypokalaemia Hyponatraemia
What other blood tests results might be seen in hyperthermia?
Elevated CK
Elevated urea
Elevated ALT and AST
What is the management of hyperthermia?
Remove excess clothingRapid active cooling:- Wetting and fanning the skin - Wetted ice packs Oxygen IV fluids Small dose benodiazepines
What temperature should patients with hyperthermia be cooled to?
No less than 39 derees
Why are IV benzodiazepines sometimes given in hyperthermia?
IV benzos increase shivering, which causes heat gain and makes cooling less effective - this ensures that patients are not cooled too much or too quickly
Why do pressure ulcers occur?
They develop in patients who are unable to move due to illness, paralsis or advancing age
What are the risk factors for pressure ulcers?
Malnutrition Incontinence Lack of mobility Pain
What is a grade 1 pressure ulcer?
Non-blanchable erythema of the skin Discolouration of the skin, warmth, oedema, induration, or hardness of the skin may be seen
What is a grade 2 pressure ulcer?
Partial thickness skin loss involving the epidermis, dermis, or both
What is a grade 3 pressure ulcer?
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the fascia
What is a grade 4 pressure ulcer?
Extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
What is the management of pressure ulcers?
A moist wound environment - hydrocolloid dressings and hydrogels Referral to tissue viability nurse Surgical debridement Systemic antibiotics
