Geris Flashcards
What are the endocrine changes in the elderly?
Menopause
Somatopause - decline in GH/IGF-1
Andropause - decline in testosterone
Decrease in lean body mass with increase in fat
What are the changes in the kidney with age?
Structural: Focal and glomerlocsclerosis Tubular atrophy Interstitial fibrosis Ateriosc;erosis Declining nephron numbers reduced renal mass Functional: Decline in eGFR and Cr clearance Impaired Na conservation Impaired ability to excrete a large Na load Dec max urine concentrating ability and diluting capacity Dec hydroxylation of Vit D
What are the clinical features of delirium?
Acute onset Fluctuating course Diffuse changes in cognition (esp attention) Disturbed consciousness Delusions and hallucinations common Disturbed sleep wake cycle Emotional disturbances Hyper+Hypo+Mixed forms
Hypoactive delerium has a worse prognosis. T/F
True
What is the pathophysiology of delirium?
Cholinergic deficiency Anticholinergic -> delirium in healthy individuals Excess dopamine has a role in delrium DA antagonist (antipsychotics) can Tx symptoms of delirium Excess cortisol implicated. Chronic stress -> activation of SNS -> chronic hypercortisolism -> may affect 5HT receptors and contribute to delirium
What are the RF for delirium?
Predisposing:
Underlying brain diseases incl dementia, CVA, PD
Advanced age
Sensory impairment
Precipitating:
Medications - opioids, anticholinergics, pyschoactive
Drug/EtOH withdrawal
Neuro - stroke, haemmorhage
Intercurrent illness
Sx
Environmental - immobility, restraints, IDC, ICU, pain, sleep deprivation
What is the median duration of delirium and outcomes?
7 days
96% do not fully resolve at discharge, 30% relapse, may persist for 6-12 months
Which drugs have high anticholinergic activity?
TCA Atropine Benztropine Chlorpromazine Oxybutynin Promethazine
When does Delirium tremens typically start? Symptoms associated? Pathophys?
48-96h after cessation Hallucinations Disorientation Tachycardia, HT, Fever, Disaphoresis Agitation Chronic EtOH desensitises the GABA receptors such that more inhibition is required to maintain a constant inhibitory tone. GABA receptor complex contains highly specific binding sites for ethanol.
Tx to prevent Wernicke’s encephalopathy?
Thiamine and glucose
What is the definition of dementia, DSM-IV?
Impairment of memory +
Impairment of at least one other cognitive domain (apraxia, aphasia, agnosia, executive function) AND
this causes a decline from previous level of function that interferes with ADLs and there is no evidence for a reversible cause
What is the difference between amnestic vs. non-amnestic mild cognitive impairment?
Amnestic - clinical significant predominant memory decline but not meeting dementia
Non-amnestic - subtle decline in functions not related to memory i.e. attention, language or visuospatial skills
What are the RF for Mild Cognitive Impairment?
Degree of CI at presentation
Predominant amnestic type on neurotesting
Apoliprotein (APOE) 4 allel carriage
MRI - hippocampal strophy, large ventricualr volumes
FDG-PET - hypometabolism
PET - uptake of amyloid binding tracers indicating amyloid plaques
CSF- low B-amyloid peptide and/or increased tau protein
What is the most common form of dementia in the elderly?
AD, 60-80%
What is a prominent feature of AD?
Short term memory loss
What are the RF for Alzheimer’s disease?
Age, 50% over 90 y FHX Multiple head injuries MCI Apoliprotein E4 allele, controversial but yes if in presence of head injury Down syndrome, > 50% over 50 y
List the 3 genes known to increase AD and associated with early onset AD?
Presenilin 1 (PSI)-Chr 14
Presenilin 2 (PS2) - Ch 1
Amyloid precursor protein (APP) - Chr 21
AND Down’s syndrome
List the gene known to increase the likelihood of late onset AD?
ApoE4-Chr 19
What are the AE of cholinesterase inhibitors (Donepezil, Rivastigmine, Galantine)?
PBS criteria?
Cholinergic effects - nausea, vomting, diarrhoea, delirium and bradycardia
PBS criteria
- MMSE > 10 upon inititation
Cholinesterase inhibitors are not effective in which dementia?
Frontotemporal dementia
What are the strong RF for falls in eh elderly?
Impaired cognition Stroke PD Multiple chronic illnesses >4 medications Psychoactive medication BZD Antidepressants Antipsychotics
Mx of Urge incontinence (involve loss of urine accompanied or preceded by urgency)? AE?
Reduce detrusor muscle contractility with anticholinergic agents e.g. oxybutynin, tolterodine, Solifenacin
AE dry mouth, constipation, urinary retention and cognitive problems
Mx of stress incontinence (involuntary leakage on stress or exertion)?
increase urethral resistance
What Tx confers the best outcome for pure stress incontinence in comparison to pelvic floor exercises alone?
Pubovaginal sling Sx (NEJM 2013)
Commonest type of incontinence in elderly?
Urge incontinence
Commonest type of incontinence in women > 60y?
Mixed incontinence
What are anticholinergics CI in?
Angle closure glaucoma
FHx of dementia. What would be the most effective intervention in preventing dementia?
Attending 3 group exercises/week
Gingko, low dose aspirin and fish oil tablets have not been shown to prevent dementia in prospective studies.
What cardiac changes in the heart occur with normal ageing?
Left atrium enlarges, LA volume increases by 50% from 3rd decade to 8th
Left ventricle hypertrophies, increase in wall thickness of 10%
Ventricular myocytes hypertrophy in response to increased after load produced by large artery stiffening
Decrease in maximum HR response to exercise
Intrinsic HR decreases by 5-6 bpm
The cumulate of age related CV changes is a decrease in maximum work, measured s max O2 utilisation on exercise testing
Examples of subcortical vs cortical dementias.
Cortical:
frontal
temporal
hippocampus
Subcortical: Basal ganglia - PD brainstem nuclei cerebellum periventricular white matter caudate and putamen in Huntington's
What are the clinical symptoms of cortical vs. subcortical dementia?
Cognitive /Exec function - Amnesia, dyscalculia, dysphasia, dyspraxia, agnosis prominent, Visuospatial deficits, poor abstraction
Motor function - minimal mild to moderate dysfunction, posture upright
Speech - usually normal until late in course
Mood - apathetic/indifferent. Euthymia present
Subcortical:
Cognitive/Exec function - forgetfullness, psychomotor reatrdation, slowed thinking (bradyphrenia), independent of motor slowness, poor strategic skills
Motor - Epilepsy syndrome, chorea, dystonia, tremor moe common, posture stooped and wide based gait
Speech - dysarthria common
Mood - Depression, dysphoria, agitation. Euthymia rare
Why does Donepazil cause bradycardia?
- reversibly and non competitively inhibits central acting acetylcholinesterase, the enzyme responsible for the hydrolysis of acteylcholine
- Results in increased concentration of acetylcholine available for transmission in the CNS
What is the most common type of dementia?
Alzheimer’s disease followed by dementia with lewy bodies.
What is the Dx criteria for dementia with lewy bodies? What is the most common prominent deficit first?
2 of 3 core clinical features:
- Visual hallucinations
- Cognitive fluctuations
- Parkinsonism
Memory loss is the first and most prominent deficit
What are the main clinical manifestations of AD?
Memory impairment is an essential feature and distinctive.
Declarative memory for facts and events, episodic memory loss, (mensal temporal and neocortical structures) are affected.
Procedural memory and motor learning memory (subcortical systems) are spared until late.
Semantic memory (vocabulary and concepts) become impaired later ( semantic memory - encoded in neocortical temporal regions).
How are Benzos cleared? Reversal Tx?
Hepatic, 95%
Renal, 5%
Tx: Flumazenil, benzo antagonist.
What are the 3 GABA receptors?
- GABA-A receptors are composed of five subunits that together form the chloride channel, which primarily mediates neuronal excitability (seizures), rapid mood changes, clinical anxiety, and sleep
- GABA-B receptors mediate memory, mood, and analgesia
- GABA-C receptors’ role remains unclear
MOA of memantine?
NMSA antagonist
AE - fatigue, peripheral oedema
CI in epilepsy
What is the main RF for delirium in older people?
Cognitive impairment - Dementia etc
What class of drugs is associated with the greatest risk of falls?
- Antidepressants
- Antipsychotics and neuroleptics
- Benzos
List the 5 features of frailty?
Weakness in hand grip Slowness Low level physical activity Exhaustion - self reported Weight loss
What is the most common cause of epilepsy in elderly people?
Stroke then
Dementia
Depression
Memory loss is AD correlates with which brain region?
Hippocampus
- formation of memory about experience events
- Hippocampal volume liss is often seen in AD
What is the criteria for Midl Cognitive Impairment?
Memory complaint Normal activities of daily living Normal general cognitive function Abnormal memory for age Not demented
What do the following ethical principles mean? Autonomy Beneficence Non maleficence Equity Competency
Autonomy
- right to self determination
Beneficence
- serve the best interest of patients
Non maleficence
- first do no hram
Equity
- right to access highest attainable standard of health as most advantaged group in a society
Competency
- ability to make decision. competent unless proven otherwise.
what is the cut off for donepazil?
MMSE 24-25
Treat in early stages
Not indicated in severely CI
What are the MRI findings in AD?
Mesial temporal lobe atrophy
Temporoparietal cortical atrophy
The memory decline is AD is rapid or progressive?
Progressive
When is Memantine (NMDA antagonist) indicated in AD?
What is Memantiine CI in?
Moderate to severe for the treatment of symptoms
Benefit in cogition, ADLs and behaviour
CI in epilepsy
What is the strongest RF fir developing vascular dementia?
Previous stroke
Loss of episodic memory is associated with vascular dementia. T/F
False
What is the association with walking speed and BP in terms of mortality in the elderly?
Higher systolic BP was associated with increased risk of mortality among elderly pts with medium to fast walking pace.
Elevated systolic and diastolic BP was strongly associated with a lower mortality risk in patients who did not complete the walk test (slow walkers).
Risk factors for future falls?
No 1. Hx of falls
2. Clinically detected abnormalities in gait or balance
What is the most common cause of blindness in elderly caucasions?
Macular degeneration.
Which intervention has been demonstrated to extend maximal life span in animals?
Caloric restriction
What is characteristic of healthy aging muscles?
Type 2 fibre atrophy
How to hold the freaking cane in OA
Hold the cane in the other freaking hand to the sore leg and advance with sore leg.
