Geris + palliative Flashcards
Q: What is another name for acute confusional state?
A: Delirium or acute organic brain syndrome.
Q: Name three predisposing factors for acute confusional state.
A: Age > 65 years, background of dementia, significant injury (e.g. hip fracture), frailty or multimorbidity, polypharmacy.
Q: List three precipitating events for acute confusional state.
A: Infection (e.g. urinary tract infections), metabolic issues (e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration), change of environment, any significant cardiovascular, respiratory, neurological, or endocrine condition, severe pain, alcohol withdrawal, constipation.
Q: What type of memory disturbance is more prominent in acute confusional state?
A: Loss of short-term memory is greater than long-term memory.
Q: What are some features of acute confusional state?
A: Memory disturbances, agitation or withdrawal, disorientation, mood change, visual hallucinations, disturbed sleep cycle, poor attention.
Q: What is the first-line sedative recommended by the 2006 Royal College of Physicians guidelines for managing acute confusional state?
A: Haloperidol 0.5 mg.
Q: According to the 2010 NICE delirium guidelines, what medications can be used to manage acute confusional state?
A: Haloperidol or olanzapine.
Q: Why can management of acute confusional state be challenging in patients with Parkinson’s disease?
A: Antipsychotics can often worsen Parkinsonian symptoms.
Q: What medications are preferred for urgent treatment of symptoms in Parkinson’s patients with acute confusional state?
A: The atypical antipsychotics quetiapine and clozapine.
Q: Besides treating the underlying cause, what is another management strategy for acute confusional state?
A: Modification of the environment.
Q: What type of disease is Alzheimer’s and what percentage of dementia cases in the UK does it account for?
A: Alzheimer’s disease is a progressive degenerative disease of the brain, accounting for the majority of dementia cases in the UK.
Q: What non-pharmacological management does NICE recommend for Alzheimer’s disease?
A: Offering ‘a range of activities to promote wellbeing that are tailored to the person’s preference’ and group cognitive stimulation therapy for patients with mild and moderate dementia.
Q: Name two other non-pharmacological therapies that may be considered for Alzheimer’s disease according to NICE.
A: Group reminiscence therapy and cognitive rehabilitation.
Q: Which three acetylcholinesterase inhibitors are recommended by NICE for managing mild to moderate Alzheimer’s disease?
A: Donepezil, galantamine, and rivastigmine.
Q: What is memantine and in what situations is it recommended by NICE?
A: Memantine is an NMDA receptor antagonist recommended for patients with moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors, as an add-on drug for moderate or severe Alzheimer’s, or as monotherapy for severe Alzheimer’s.
Q: What is NICE’s stance on the use of antidepressants for depression in patients with Alzheimer’s disease?
A: NICE does not recommend antidepressants for mild to moderate depression in patients with dementia.
Q: Under what circumstances does NICE recommend the use of antipsychotics in Alzheimer’s patients?
A: Antipsychotics should only be used for patients at risk of harming themselves or others, or when agitation, hallucinations, or delusions are causing severe distress.
Q: What is a relative contraindication for the use of donepezil?
A: Donepezil is relatively contraindicated in patients with bradycardia.
Q: What is an adverse effect of donepezil?
A: Insomnia.
Q: What type of disease is Alzheimer’s, and what percentage of dementia cases in the UK does it account for?
A: Alzheimer’s disease is a progressive degenerative disease of the brain, accounting for the majority of dementia cases in the UK.
Q: List three risk factors for Alzheimer’s disease.
A: Increasing age, family history of Alzheimer’s disease, and Caucasian ethnicity.
Q: What percentage of Alzheimer’s cases are inherited as an autosomal dominant trait, and what genes are involved?
A: 5% of cases are inherited as an autosomal dominant trait. The involved genes include amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14), and presenilin 2 (chromosome 1).
Q: Which apoprotein allele is associated with Alzheimer’s disease, and what does it encode?
A: Apoprotein E allele E4 is associated with Alzheimer’s disease, and it encodes a cholesterol transport protein.
Q: Why is Down’s syndrome a risk factor for Alzheimer’s disease?
A: Individuals with Down’s syndrome have an extra copy of chromosome 21, which contains the gene for amyloid precursor protein, leading to an increased risk of developing Alzheimer’s disease.
Q: Describe the macroscopic pathological changes seen in Alzheimer’s disease.
A: Widespread cerebral atrophy, particularly involving the cortex and hippocampus.
Q: What are the microscopic pathological changes seen in Alzheimer’s disease?
A: Cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein.
Q: What biochemical deficit is seen in Alzheimer’s disease?
A: There is a deficit of acetylcholine due to damage to an ascending forebrain projection.
Q: What are neurofibrillary tangles, and what protein are they partly made from?
A: Neurofibrillary tangles are paired helical filaments partly made from a protein called tau.
Q: What is the function of tau protein in a healthy brain, and how is it impaired in Alzheimer’s disease?
A: Tau protein interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules. In Alzheimer’s disease, tau proteins are excessively phosphorylated, impairing its function.
Q: What is a key characteristic of the onset of delirium compared to dementia?
A: Delirium has an acute onset.
Q: How does the impairment of consciousness differ between delirium and dementia?
A: Impairment of consciousness is present in delirium but not typically in dementia.
Q: Describe the fluctuation of symptoms in delirium.
A: Symptoms of delirium fluctuate, often being worse at night with periods of normality.
Q: What type of abnormal perception is more indicative of delirium than dementia?
A: Illusions and hallucinations are more indicative of delirium.
Q: What emotional states are commonly associated with delirium?
A: Agitation and fear.
Q: Are delusions more common in delirium or dementia?
A: Delusions are more common in delirium.
Q: What are the most common causes of dementia in the UK?
A: Alzheimer’s disease, followed by vascular and Lewy body dementia.
Q: Name two assessment tools recommended by NICE for diagnosing dementia in a non-specialist setting.
A: 10-point cognitive screener (10-CS) and the 6-Item cognitive impairment test (6CIT).
Q: Which assessment tools are not recommended by NICE for diagnosing dementia in a non-specialist setting?
A: Abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG), and mini-mental state examination (MMSE).
Q: What MMSE score suggests dementia?
A: A score of 24 or less out of 30.
Q: What tests does NICE recommend in primary care to exclude reversible causes of dementia?
A: FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12, and folate levels.
Q: To whom are patients commonly referred for dementia evaluation?
A: Old-age psychiatrists, sometimes working in ‘memory clinics’.
Q: What is the purpose of neuroimaging in secondary care for dementia patients?
A: To exclude other reversible conditions (e.g., subdural haematoma, normal pressure hydrocephalus) and to provide information on aetiology to guide prognosis and management.
Q: According to the 2011 NICE guidelines, what is considered essential in the investigation of dementia?
A: Structural imaging.
Q: What are the most common causes of dementia?
A: Alzheimer’s disease, cerebrovascular disease (multi-infarct dementia, 10-20%), and Lewy body dementia (10-20%).
Q: Name three rarer causes of dementia that account for approximately 5% of cases.
A: Huntington’s disease, Creutzfeldt-Jakob disease (CJD), and Pick’s disease (atrophy of frontal and temporal lobes).
Q: What percentage of AIDS patients are affected by dementia due to HIV?
A: 50% of AIDS patients.
Q: List three important differentials of dementia that are potentially treatable.
A: Hypothyroidism, Addison’s disease, and B12/folate/thiamine deficiency.
Q: Name three more potentially treatable causes of dementia.
A: Syphilis, brain tumour, and normal pressure hydrocephalus.
Q: What condition caused by head injury is an important differential for dementia?
A: Subdural haematoma.
Q: Which mental health condition is an important differential for dementia?
A: Depression.
Q: Name two types of chronic drug use that can be important differentials for dementia.
A: Alcohol and barbiturates.
Q: What systems are involved in normal gait?
A: The neurological system (basal ganglia and cortical basal ganglia loop), the musculoskeletal system, and effective processing of senses such as sight, sound, and sensation (fine touch and proprioception).
Q: Name three medical conditions that can lead to gait abnormalities and increase the risk of falls in the elderly.
A: Diabetes, rheumatoid arthritis, and Parkinson’s disease.
Q: List five risk factors for falling in the elderly.
A: Lower limb muscle weakness, vision problems, polypharmacy (4+ medications), incontinence, and depression.
Q: What is the significance of having four or more risk factors for falling?
A: Individuals with four or more risk factors have up to a 78% chance of falling.
Q: What should be established from the history when assessing a patient who has fallen?
A: Where and when the patient fell, any witnesses, associated features before/during/after the fall, why the patient thinks they fell, past falls, systems review, past medical history, and social history.
Q: Why is it important to review a patient’s medication when assessing falls risk?
A: Patients on more than four drugs are more likely to fall, so suspect or unnecessary medications should be stopped or swapped.
Q: Name two types of medications that can cause postural hypotension and are associated with falls.
A: Nitrates and diuretics.
Q: What bedside tests are important when investigating falls?
A: Basic observations, blood pressure, blood glucose, urine dip, and ECG.
Q: What blood tests should be considered when investigating falls?
A: Full Blood Count, Urea and Electrolytes, Liver function tests, and bone profile.
Q: What imaging might be required when investigating falls in the elderly?
A: X-ray of chest/injured limbs, CT head, and cardiac echo.
Q: What functional tests are recommended for patients with a history of falls?
A: The ‘Turn 180° test’ or the ‘Timed up and Go test’.
Q: Who should be offered a multidisciplinary assessment after a fall?
A: Patients over 65 with more than two falls in the last 12 months, a fall that requires medical treatment, or poor performance/failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Q: What should be done for individuals who fall but do not meet the criteria for a multidisciplinary assessment?
A: They should be reviewed annually and given written information on falls.
