Gerrys Flashcards
Delirium
Acute, fluctuating course of change in mental status. Inattention, altered level of consciousness. Reversible.
Hyperactive - increased level of arousal, restlessness, hallucinations
Hypoactive - lethargy, reduced motor activity, lack of interest
Mixed
Risk fx:
Older age, dementia, dehydration, visual/hearing impairment, polypharmacy
Insults: Drugs: sedatives, anticholinergics, opiates, corticosteroids Neuro: stroke, meningitis Acute illness: infection, shock Surgery Pain Drug withdrawal: alcohol, benzos
Ix:
4-AT test: screening for cognitive impairment and delirium
4 or more: possible delirium +/- cognitive impairment
Alertness, AMT4 (DOB, age, place, current year)
Attention (months of year backwards)
Acute change or fluctuating course
Examination: Hydration Lung examination - pneumonia, COPD Cardio exam - coronary disease Abdo exam - constipation, intra-abdo sepsis Palpable bladder - urinary retention Hip tenderness - hip fracture
Ix: FBC (anaemia) Urinalysis ECG (MI) ABG (hypoxia) CXR (penumonia) Drug levels (digoxin, alcohol)
Tx:
Manage underlying cause
TIME bundle (triggers, investigate, manage, engage)
Reorientate person
Treat symptoms:
Involve family to reassure and support
Consider capacity to consent to treatment (AWI)
Medications if unmanagable agitation: Haloperidol, Lorazapam
Refer to liasion psychiatry (if severe agitation)
Treat environment: Ensure glassess/hearing aids work Ensure adequate diet/hydration Ensure enough O2 Getting to know me booklet
Preventing delirium:
Avoid moving person to diff wards
Within 24 hrs, assess risk for clinical factors contributing to delirium
Ensure proper hydration/constipation
Address infection: avoid unnecessary catheterisation
Encourage mobilisation soon after surgery
Ensure adequate pain management
Address sensory impairment: hearing aids working
Dementia
Mild cognitive impairment: decrease in cognition but not affecting daily living
Dementia: Decrease in cognition leading to behavioural problems and impairment in activities of daily living
PD dementia: symptoms of dementia >1 year after motor sx
Dementia with Lewy Bodies: sx of dementia <1yr before motor sx (dementia always appears first)
DDx: delirium, MCI, depression, vascular demetia, LBD, FT dementia
MCI
MMSE >24
fluorodeoyglucose-PET scan: low uptake
MRI brain: atrophy
AD
Chronic degenerative disorder with insidious onset, and progressive decline
Characterised by loss of memory, personality change, loss of social/occupational functioning
Sx: memory loss, disorientation, personality change, decline in ADL Signs: constructional dyspraxia (parietal lobe deficit - difficulty completing clock on MMSE) Nominal dysphasia (difficulty naming objects)
Ix: MMSE (impaired recall, disorientation (time/place), constructional dyspraxia (can't assemble things/draw objects) FBC, UEs (hypo/hyper Na, glucose) Serum B12 TFTs CT head (exclude other causes) MRI (generalised atrophy)
Tx:
Supportive (use clocks, calenders to orientate person to time), ensure environment safe, communication (short, simple sentences)
OT assessment (bracelets, motion detectors)
Cholinesterase inhibitors:
Donezipil
Rivastigmine
Moderate/severe AD: memantine (NDMA antagonist)
Vascular dementia
Executive functions e.g. planning are more affected than memory
Due to vascular cause e.g. ischaemia, infarction, small vessel disease
Sx:
risk fx: stroke
sx of frontal cognitive syndrome: difficulty solving problems, disinhibition, apathy
Signs: UMN signs, impaired gait
Ix: FBC, glucose, TFTs, B12/folate (exclude other causes)
MRI/CT brain
Tx:
Aspirin
Carotid endartectomy
BP control, statin
Dementia with Lewy bodies
Characterised by fluctuating cognition, visual hallucinations, REM sleep behaviour disorder
and one or more of:
sx of PD (rigidity, bradykinesia, resting tremor)
Tx: Cholinesterase inhibitors
Motor sx: Carbidopa/levodopa
Fronto-temporal dementia
Second most frequent degenerative disease (after AD) <65yrs
Onset 50s
Sx: personality changes, social disinhibition, language
Ix: MMSE
CT/MRI head (atrophy of frontal/temporal lobes)
Tx: supportive
benzos e.g. lorazepam (agitation)
Depression
> 5 symptoms during 2 week period:
Persistent low mood, anhedonia (loss of interest in usual activities), reduced energy, weight changes, reduced libido, sleep disturbance, excessive guilt, poor conc, reucurrent suicidal ideation
Causes functional impairment (social, occupational)
Ix: Clinical diagnosis, FBC (anaemia), TFTs (hypothyroid), geriatric depression scale, MMSE
Tx: Citalopram (selective serotonin reuptake inhibitor) SE: QT prolongation, arrhythmias, headache Selegilline (MAOI) Psychotherapy CBT
Malnutrition
Defined by
BMI <18.5
Unintentional weight loss >10% within 3-6 mnths
BMI >20, unintentional weight loss >5% within 3-6 months
Oral, enteral, parenteral
Enteral:
Nutrition placed directly into stomach/SI
NG, NJ, PEG (percutaneous endoscopy gastrostomy - tube placed through abdo wall to stomach)
Inadequate/unsafe oral intake+functional GI tract
Indications: stroke
Complications: aspiration pneumonia, infection, irritation nose
Parenteral:
Nutrition placed in bloodstrea via IV
Inadequate/unsafe oral intake+ non functioning or perf GI tract
Given by central venous catheter
Indications: malnourished pts for surgery, chemo, radiotherapy
Complications: gallstones, cholestasis, infection, thrombosis (clot forming around catheter in vein)
Deterioration in mobility
Gait and balance assessment Watching pt walk Foot drop (peripheral neuropathy) High stepping gait Tredenlenburg (hip weakness due to MSK problems) Ataxic gait (cerebellar issues) PD signs (freezing, shuffling gait) Antalgic gait (weakness, pain)
Tests for walking/balance
Timed up and go test (sit in chair, stand, walk 3 metres and sit back down)
>12s: maybe impaired
Chair stand:
Pt sit in chair and ask them to stand
If need to use arms - lower limb impairment
Falls
Multifactorial risk assessment
Assess history of falls, gait/balance, cognitive impairement, cardiovascular examination, OP risk, perceived ability/fear of falling, visual impairment
Causes:
Motor impairment: gait, balance, muscle weakness
Sensory impairment: visual (macular degeneration, cataracts), hearing
Cardiovascular: AS, postural hypotension, vasovagal
Cognitive: dementia, delirium
Environmental: loose rugs, poor lighting
Polypharmacy
Orthostatic hypotension
Ix: FBC, B12, folate, glucose, UEs ECG (syncope) Echo (hx of heart disease) XR bones (if pain) CXR CT head (if head injury) Bone scan Lying/standing BP
Tx: Referred to community falls prevention programme (offer home assessment within 5 days, help and advice, specialist referral e.g. falls clinic, podiatrist) Strength and balance training Minimise pyschoactive meds Manage postural hypotension Manage foot problems
Falls clinic:
Nurse: lying/standing BP, continence, ECG
Physio: MSK/neuro exam
Medical: hx and exam inc. Hallpike test (BPPV Benign paroxysmal positional vertigo)
Continence
Causes of urinary incontinence:
Weak pelvic floor muscles, overactive bladder, BPH
Red flags: saddle anaesthesia, back pain, Ca.
Sx: dysuria, loin pain, haematuria,
Urinary incontinence history:
Fluid intake, coffee
PMHx: Ca, neuro, urology
DHx: diuretics, amitriptyline
Ix:
Urinalysis - dipstick, MSU
Abdo exam
Bladder scan
Bowel incontinence hx: Constipation/diarrhoea Bristol stool chart Frequency Women - childbirth Drug hx: codeine, loperamide, laxatives
Ix:
Neuro/abdo exam
PR
Sigmoidscopy
Cauda equina syndrome;
When cauda equina (bundle nerves below spine) is damaged
Sx: low back pain, pain radiates down leg, incontinence (urinary/bowel)
Ix: MRI spine Catheter ECG, CXR, PSA, myeloma/bone profile OIf tumour - give dexamethasone
DDx: spinal stenosis, disc prolapse, alk spond
Female:
Lifestyle advice: reduced caffeine, lose weight
Pelvic floor muscle training 3 mnths
Bladder training - urgency or mixed urinary incontinence
Transcutaneous electrical nerve stimulation
Anticholingerics - overactive bladder
Causes of bowel incontinence:
Weak bowel muscles
Changes in nerves innervating bowel
Diarrhoea
Tx: Loperamide Pelvic floor muscle training Bowel retraining Biofeedback Sphincter repair
Frailty
A physiological syndrome characterised by loss of reserve and resistance to stressors, leading to vulnerability to adverse outcomes
Fried frailty criteria: Unintentional weight loss Tired Weakness (by grip strength) Slowness (by timed up and go) Low activity levels >3 = frail
Pressure ulcers
Injury to skin and/or underlying tissue, usually over bony prominence, due to pressure
Aetiology: pressure, shear, friction, moisture
Risk fx: increased age, reduced mobility, neuro impairment leading to loss of sensation, malnutrition
Sx: non-blanching erythema, or discoloured intact skin
Grade 2: dry, shallow ulcer
Grade 3: full-thickness wound containing some slough
Grade 4: Full thickness wound with exposed bone/tendon, containing slough
Ix: Clinical diagnosis Wound swab (infection)
Tx: pressure reducing aids e.g. pressure mattress, seat cushoins
Grade 2/3: good hygiene, skin care, dressings, analgesia, dietitian referral
Grade 3/4: debridement necrotic tissue e.g. sharp debridement, maggots + dressings
Surgery + reconstruction with flap
Hearing loss
Conductive hearing loss: loss in external/middle ear, so can’t be transmitted to inner ear. Many causes treated with surgery
Sensorineural: occurs in inner ear or auditory nerve. Many causes permanent as limited ability to heal itself
Causes:
External ear:
Impacted wax (most common)
Foreign body
Trauma
Infections e.g. pseudomonas, Staph
Middle ear:
Otitis media (red, bulging, tympanic membrane)
Osteosclerosis - bone growth at foot of stapes, so less sound transmitted to cochlea
Paget’s disesase of bone
Inner ear:
Presbycusis (loss of sensorineural hearing due to age (mostly high pitched loss, bilateral)
Noise-related hearing loss
Ototoxic drugs e.g. Aminoglycodes - Gent, Amikacin, loop diuretics
Labrynthitis: sudden hearing loss, tinnitus, pressure in ear, vertigo
Meniere’s disease: Unilteral fluctuating hearing loss, tinnitus, vertigo, recurrent
Tumours: Vestibular schwannoma: unilateral hearing loss, imbalance
Visual disorders
Glaucoma
Neurodegenerative disorder due to dysfunction in outflow of aqueous humor. Leads to increase in intra-ocular pressure, and retinal ganglion cell damage, peripheral vision loss then central vision loss
Cataracts
Opacification of lens due to aging, trauma
Risk fx: age, long term use steroids, diabetes
Sx: blurred/cloudy vision, reduced visual acuity
Macular degeneration
Leading cause of adult blindness
Risk fx: age, family fx, previous cataract surgery, smoking
Sx: sudden onset blurring of vision
Early: drusen (yellow deposits of lipid/fat under retina)
Intermediate: macular pigmentatory changes
Late: Atrophy, significant visual loss inc. central macula (fovea)
Ix: Optical coherence tomography
Elder abuse
Failure of carer to provide basic needs to older person, leading to harm/likely harm
Neglect, physical, psychological, financial, sexual
Sx: self-report, inconsistence hx in patient, or between carer and pt, agitated (unexplained fear, no eye contact), malnutrition
Tx: report to social services, sharing information with law enforcement
Pharmacology
Decrease in body water, so volume of distribution of water soluble drugs is decreased. So loading dose needs to decrease e.g. digoxin
Fat-soluble drug e.g. benzos will accumulate and have a longer half-life
